New York State Medicaid Update - June 2023 Volume 39 - Number 11

In this issue …

New York State Department of Health Telehealth Consumer Survey Results Now Available

The Telehealth Consumer Survey results are now available on the NYS Medicaid Telehealth website, via infographic, in the following languages: Arabic, Bengali, Chinese, English, Haitian-Creole, Italian, Korean, Polish, Russian, Spanish and Yiddish.

Background

In order to better understand patient perspectives on telehealth during the Coronavirus Disease 2019 (COVID-19) public health emergency (PHE), the New York State (NYS) Department of Health (DOH) Office of Health Insurance Programs (OHIP) partnered with the Office of Addiction Services and Support (OASAS), Office of Mental Health (OMH), Office of Children and Family Services (OCFS), and the Office for People with Developmental Disabilities (OPWDD) to conduct the Telehealth Consumer Survey. All NYS residents, whether they have used telehealth services or not, were encouraged to complete the survey, which was active from May 2022 through August 2022 and available for all New Yorkers to complete. Survey results are being used to inform future telehealth policy development in NYS.

Questions

All questions regarding the Telehealth Consumer Survey results infographic should be sent to the NYS DOH at Telehealth.Policy@health.ny.gov.

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New York State Extends Medicaid and Child Health Plus Postpartum Coverage from 60 Days to One Year

New York State (NYS) Medicaid and Child Health Plus (CHPlus) have extended the duration of postpartum health coverage from 60 days to a full year following pregnancy, regardless of immigration status or how the pregnancy ended. New York is the 35th state to adopt a federal option included in the Biden Administration's Maternity Care Action plan to extend postpartum coverage, with the overarching goal of improving maternal health, particularly in disadvantaged communities.

The postpartum period is critical for recovering from childbirth, addressing complications of delivery, ensuring mental health, managing infant care, and transitioning from obstetric to primary care. A recent release of maternal mortality rates provided by the Centers for Disease Control and Prevention (CDC), shows in 2021, 1,205 women died of maternal causes in the United States (U.S.), compared with 861 in 2020 and 754 in 2019. According to the Assistant Secretary for Planning and Evaluation (ASPE) Medicaid After Pregnancy: State-Level Implications of Extending Postpartum Coverage document, one in three pregnancy-related deaths occur between six weeks and one year after childbirth. This option to extend NYS Medicaid and CHIP postpartum coverage is part of ongoing efforts to address disparities in maternal health outcomes by opening the door to postpartum care for thousands of people.

To read the NYS Department of Health (DOH) announcement on this benefit extension, providers should refer to the NYS DOH "New York State Department of Health Extends Medicaid and Child Health Plus (CHPlus) Postpartum Coverage from 60 Days to One Year" web page.

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Billing Guidance for Reporting Newborn Birth Weights

The New York State (NYS) Department of Health (DOH) reminds hospitals to accurately report newborn birth weights on inpatient claims. Pursuant to the inpatient billing procedures for All Patients Refined Diagnosis Related Groups (APR DRGs) documented in the eMedNY New York State UB-04 Billing Guidelines - Inpatient Hospital document, claims for newborns must accurately contain the newborn's birth weight in grams. The birth weight is reported using Value Code "54" in the Value Information segment. To ensure proper payment when billing Medicaid fee-for-service (FFS), providers should follow the billing guidelines detailed in the eMedNY New York State UB-04 Billing Guidelines - Inpatient Hospital document (2.3.1.2, Rule 3 - Newborns).

Questions and Additional Information:

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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.

Reminder: Record Retention, Furnishing of Records, and Permitting Audit and Cooperation with Governmental Agencies

As New York State (NYS) Medicaid-enrolled providers, in accordance with Title 18 of the New York Codes, Rules and Regulations (NYCRR) §504.3(a) and §504.3(g), the pharmacy owner and the supervising pharmacist are responsible for:

  • preparing and maintaining contemporaneous records demonstrating the right to receive payment under the medical assistance program [refer to 18 NYCRR §504.3(a)];
  • keeping for a period of six years from the date the care, services or supplies were furnished, all records necessary to disclose the nature and extent of services furnished and all information regarding claims for payment submitted by, or on behalf of, the provider [refer to 18 NYCRR §504.3(a)];
    • Please note: Providers continue to be subject to any additional record retention requirements outlined in their prior or current contracts with Medicaid Managed Care (MMC) or Managed Long Term Care (MLTC) Plans or Subcontractors thereof, including retention for 10 years or more as delineated therein.
  • furnishing such records and information, upon request, to the Secretary of the United States Department of Health and Human Services (HHS), the Deputy Attorney General for Medicaid Fraud Control (MFCU) and the NYS Department of Health (DOH) [refer to 18 NYCRR §504.3(a)]; and
  • permitting audits of all books and records or, in the discretion of the auditing agency, a sample thereof, relating to services furnished and payments received under the medical assistance program, including patient histories, case files and patient-specific data [refer to 18 NYCRR §504.3(g)].

Policy guidelines regarding pharmacy documentation and record keeping requirements are contained in the NYRx, NY Medicaid Pharmacy Program Pharmacy Manual - Policy Guidelines.

The NYS Office of the Medicaid Inspector General (OMIG) is an independent office within NYS DOH. Pharmacy audit protocols developed and issued by NYS OMIG for services January 1, 2015 through December 31, 2019, can be found on the NYS OMIG "Audit Protocols" web page. Updated protocols are in development. NYS OMIG regulations, including 18 NYCRR §504.3 (Duties of the Provider), can be found in their entirety on the NYS OMIG "Laws and Regulations" web page.

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340B Claim Reminder for Covered Entities and Contract Pharmacies

New York State (NYS) Medicaid continues to accept appropriately submitted claims for 340B-purchased drugs. Federal law 42 United States Code (USC) 256b(a)(5)(A)(i), prohibits duplicate discounts, such that drug manufacturers are not required to provide a discounted 340B price and a Medicaid drug rebate for the same drug. To prevent duplicate discounts from occurring, NYS Medicaid exclusively uses claim level identifiers on either National Council for Prescription Drug Programs (NCPDP) or Professional/Institutional claim types (837P/837I). Information on how outpatient clinics bill for 340B can be found in the Clarification of Previous Guidance: New York State Medicaid Fee-for-Service Coverage of Practitioner Administered Drugs article published in the July 2022 issue of the Medicaid Update. The information in this article is intended to advise providers, who may be new to submitting claims to NYRx, the NYS Medicaid Pharmacy program, that all NCPDP-submitted 340B-purchased drug claims when NYS Medicaid is primary payor must be submitted with claim level identifiers and at actual acquisition cost.

Claim level identifiers are required for any 340B-purchased drug billed to NYRx, Medicaid Managed Care (MMC) Plan, or as a secondary claim, whether it is a medical or pharmacy claim. It is the responsibility of the covered entity (CE) and their contracted pharmacies, if applicable, to correctly identify claims dispensed with the 340B stock of the CE for 340B-eligible NYS Medicaid patients to ensure rebates are not collected for these drugs. If rebates are received by the NYS DOH for drugs obtained via the 340B program due to incorrect or missing claim level identifiers, the CE is responsible for reimbursing manufacturers the 340B discounts.

The following table outlines the necessary fields and their values for various claim types to identify 340B-purchased drug claims. Please note: 340B pharmacy and medical benefit claims billed to NYS Medicaid as primary payor require identifiers and actual acquisition cost, pharmacy and medical claims billed to MMC Plan as primary or NYS Medicaid as secondary payor (only require 340B claim identifiers), and the ingredient cost as required by the other payor.

Claim Type Field Fee-for-Service (FFS) or NYRx Primary Claim MMC Plan as Payor Medicare or Commercial Primary Payors when NYS Medicaid is Secondary
837P/837I Modifier UD* UD UD
NCPDP 420-DK, Submission Clarification Code (SCC) 20 20 (in limited situations when the MMC Plan allows NCPDP billing for physician administered drug dispensing) 20
NCPDP 423-DN, Basis of Cost Determination (BCD) 08 The plan should be consulted for their requirements in this field The plan should be consulted for their requirements in this field
NCPDP 409-D9, Ingredient Cost Submitted 340B Acquisition Cost* The plan should be consulted for their requirements in this field The plan should be consulted for their requirements in this field
NCPDP 426-DQ, Usual and Customary Cost (U&C) Lowest Net Charge to Cash Customers** Lowest Net Charge to Cash Customers** Lowest Net Charge to Cash Customers**

*All FFS 340B claims must be submitted at acquisition cost, by invoice, inclusive of all discounts.
**U&C is defined as the lowest price charged to the public after all applicable discounts, including promotional discounts and discounted prices associated with loyalty programs.

Outpatient Dispensed Drugs (NCPDP)

As previously communicated in the New System Edit to be Implemented to Validate the Ingredient Cost for 340B Drugs article published in the August 2019 issue of the Medicaid Update, for a NYS Medicaid FFS primary claim only, system editing will compare the ingredient cost submitted (NCPDP field 409-DK) with the 340B ceiling price for the product, as defined by the Health Resources and Services Administration (HRSA), to ensure the ingredient cost submitted is the 340B price. The 340B ceiling price refers to the maximum amount that a manufacturer can charge the CE for the purchase of a 340B-covered outpatient drug. A claim submitted to NYS Medicaid should never be higher than the 340B ceiling price. Pharmacies that submit a 340B drug claim, whenever the ingredient cost submitted is higher than the ceiling price, will be returned the Medicaid Eligibility Verification System (MEVS) Rx Denial code: "708: Exceeds NY Allowed Maximum", and the NCPDP Reject code: "78: Cost Exceeds Maximum". Claims that are denied with this reason code may be resubmitted with the correct ingredient cost.

Physician-Administered Drugs (837P/837I)

An accurate National Drug Code (NDC) and "UD" modifier must be reported for any physician-administered drug (PAD) obtained at the 340B price that is billed on the Professional or Institutional claim form for either FFS or MMC Plan. A PAD will not be paid under Ambulatory Patient Groups (APGs) if the claim does not include an accurate NDC. Please note: Providers are required to submit the NDC, the number of units administered, and the actual acquisition cost of the drug for any PAD that is payable either via an APG brand or the APG fee schedule. Providers should refer to the Clarification of Previous Guidance: New York State Medicaid Fee-for-Service Coverage of Practitioner Administered Drugs article published in the July 2022 issue of the Medicaid Update, for other important information regarding PAD 340B claim submissions.

Non-Drug Items

As communicated in the NYS Medicaid Change in 340B Claim Identification Effective 04/01/2017 article published in the December 2016 issue of the Medicaid Update, 340B claim level identifiers are required on all 340B-purchased drug claims for NYS Medicaid members. Pharmacies should not submit claim level identifiers on non-340B eligible items such as test strips. Diabetic test strips are not covered outpatient drugs and are not part of the Medicaid Drug Rebate Program (MDRP) and, therefore, are not eligible for a 340B discount. Only 340B-purchased drugs should be tagged when claim-eligible with the 340B claim level identifiers. Tagging test strips, supplies, or any other non-340B eligible item as a 340B drug causes a false claim, which may be recovered during an audit. Additional information regarding MDRP can be found on the Centers for Medicare and Medicaid Services (CMS) "Medicaid Drug Rebate Program (MDRP)" web page.

Please note: All 340B claims are subject to audit and investigation. Additionally, claims improperly identified as 340B and/or claims with unsubstantiated acquisition cost may be considered fraudulent claims. It is the responsibility of all providers, including pharmacies, 340B covered entities, and their contracted pharmacies to correctly report claims dispensed to NYS Medicaid members as true, accurate, and complete [refer to Title 18 of the New York Codes, Rules and Regulations (NYCRR) §504.4].

Questions and Additional Information:

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