New York State Medicaid Update - September 2024 Volume 40 - Number 10

In this issue …

• Policy and Billing
  • Updated Licensure Threshold Guidance for Ambulatory Services
  • Updated Medicaid Coverage of Mental Health Counseling by Licensed Clinical Social Workers and Licensed Master Social Workers Approved for Article 28 Outpatient Hospital Clinics and Free-Standing Diagnostic and Treatment Centers
  • Blood Glucose Testing and Monitoring Changes
  • Upcoming Changes to Billing Requirements for Professional Drug Claims
• All Providers
  • ePACES Self-Help Guides Available on eMedNY Website
  • Expanded Reimbursement for Adverse Childhood Experiences Screening
  • Reminder: Sign Up for eMedNY Training Webinars
  • Update to Medicaid Provider Enrollment Revalidation Requirement
• Pharmacy
  • Medication Synchronization Program Implementation
  • Vaccine Billing Update for Pharmacies: Notice of Upcoming Change
  • Reminder: NYRx Allows 90-Day Prescribing for Most Maintenance Medications and Over the Counter Drugs
  • NYRx, the Medicaid Pharmacy Program, Clinical Call Center Name Change

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.

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Updated Licensure Threshold Guidance for Ambulatory Services

The New York State (NYS) Department of Health (DOH), NYS Office of Mental Health (OMH), NYS Office of Addiction Services and Supports (OASAS), and NYS Office for People with Developmental Disabilities (OPWDD) announced updates to "licensure thresholds," effective October 1, 2024. Licensure thresholds are the amount of physical, behavioral health or diagnostic and treatment services that can be delivered by a licensed provider without requiring another license, certification, or designation by a NYS oversight agency to provide those services.

Prior to this update*, providers that wished to offer ambulatory primary care, behavioral health services or diagnostic and treatment services above the established thresholds, were required to obtain an additional license, certification, or designation from more than one NYS agency. To increase access to integrated care for individuals with co-occurring needs and ease administrative burdens on providers, NYS DOH, NYS OMH, NYS OASAS, and NYS OPWDD have updated existing licensure thresholds as outlined below.

Guidance for Providers Under Updated Licensure Thresholds

Article 28 Provider Offering Ambulatory Behavioral Health Services and/or Diagnostic and Treatment Services

Article 28 providers who wish to offer integrated ambulatory services may deliver up to 30 percent of their total annual visits for mental health, addiction and/or diagnostic and treatment services without obtaining an Article 31 license from NYS OMH, an Article 32 certification from NYS OASAS, or Article 16 certification from NYS OPWDD. The majority of services provided in an Article 28 must be physical health services.

Behavioral Health Services Provider (Article 31 and Article 32) Offering Primary Care Services

NYS DOH has raised the licensure threshold for NYS OMH Mental Health Treatment and Rehabilitative Services (MHOTRS) programs licensed pursuant to of the Title 14 New York Codes, Rules, and Regulations (NYCRR) Part 599, and Article 32 providers certified pursuant to Title 14 NYCRR Part 822, to enable them to provide up to 30 percent of their total annual visits for primary care services, without obtaining an Article 28 license from NYS DOH. Medical services that occur throughout the NYS OASAS-bedded programs are not subject to the thresholds as outlined in guidance. The guidance will be effective for NYS OMH-licensed clinics providing primary care services, when the amendment to NYS OMH Part 599 regulations becomes effective, which is necessary to effectuate the changes outlined in this guidance. The amendment is anticipated to become effective in the near future.

Mental Health Services Provider (Article 31) Offering Addiction Services and Addiction Services Provider (Article 32) Offering Mental Health Services

NYS OMH-licensed and NYS OASAS-certified providers may continue to integrate mental health and addiction services for individuals with co-occurring conditions in accordance with NYS OMH and NYS OASAS regulations and guidance. Providers are not required to obtain an Integrated Outpatient Services (IOS) license, pursuant to Title 14 NYCRR Part 598 or Title 14 NYCRR Part 825, for this purpose and such services are not subject to any thresholds. The NYS agencies are working on additional guidance regarding integrated mental health and addiction services in NYS OMH and NYS OASAS settings.

I/DD Services Provider (Article 16) Offering Primary Care Services

NYS DOH has raised the licensure threshold for Article 16 clinic providers offering diagnostic and treatment services to people with I/DDs, as determined eligible by NYS OPWDD, to enable Article 16 clinic providers to provide up to 30 percent of their total annual visits for primary care services, without obtaining an Article 28 license from NYS DOH.

Billing

At this time, providers should continue billing for comprehensive services as is currently identified in their respective billing guidance. The NYS agencies are working to publish additional guidance and will notify providers and health care plans when this guidance is available, as well as whether there are any impacts to current billing practices. Providers should refer to the full Updated Licensure Threshold Guidance for Ambulatory Services for New York State Department of Health (DOH), Office of Mental Health (OMH), Office of Addiction Services and Supports (OASAS), and Office for People With Developmental Disabilities (OPWDD) programs. Please note: This guidance does not apply to IOS licensed providers, Delivery System Reform Incentive Payment (DSRIP) 3.a.i-approved providers, and comprehensive services that are already permissible under the license, certification, or designation of the provider and defined within NYS agency regulations.*

^{1. For I/DDs. In all circumstances, services that are already permissible (e.g., Health Monitoring Services in an Article 16, Article 31 or Article 32 setting) do not count against the threshold.;1}
*Only in settings where less than 50 percent of the population served has an I/DD, as determined eligible by NYS OPWDD, and more than 30 percent of total services are diagnostic and treatment services for people with I/DDs.
**Providers can deliver integrated behavioral healthcare to individuals who meet the appropriate admission criteria, within scope and to the extent which staff have the necessary education, training, and experience.
***Notwithstanding the threshold allowances provided herein, the majority of services provided in an Article 28 must be physical health services.

Questions

Questions regarding this update should be directed to Tamara Glaser, Integrated Care Advisor for the NYS DOH Bureau of Adult Special Populations, at tamara.glaser@health.ny.gov.

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Updated Medicaid Coverage of Mental Health Counseling by Licensed Clinical Social Workers and Licensed Master Social Workers Approved for Article 28 Outpatient Hospital Clinics and Free-Standing Diagnostic and Treatment Centers

Effectively immediately, for New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans, in accordance with changes to Public Health Law (PHL) §2807, mental health counseling provided by Licensed Clinical Social Workers (LCSWs) or Licensed Master Social Workers (LMSWs) rendered in Article 28 hospital outpatient department (OPD) clinics and free-standing diagnostic and treatment centers (D&TCs) will be expanded to include all ages and patient populations.

In an Article 28 clinic, there is no limit on the patient population that can receive treatment for services provided by Licensed Mental Health Counselors (LMHCs) or Licensed Marriage and Family Therapists (LMFTs). This expansion will allow LCSWs and LMSWs, in addition to LMHCs and LMFTs, to provide mental health counseling services within their scope of practice in an Article 28 clinic with no limitations on the patient population that can receive services in this setting. The Ambulatory Patient Group (APG) payment to the clinic includes the professional component for services rendered by a LCSW, LMSW, LMHC or LMFT; a professional claim cannot be billed.

For additional information pertaining to LCSW, LMSW, LMHC, and LMFT services, providers should 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:

• 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.
• 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.
• NYS Medicaid FFS claims questions should be directed to the eMedNY Call Center at (800) 343-9000.
• NYS Medicaid FFS provider enrollment questions should be directed to eMedNY Provider Enrollment at (800) 343-9000.

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Blood Glucose Testing and Monitoring Changes

As part of ongoing efforts to ensure optimal care for New York State (NYS) Medicaid members who require blood glucose testing, NYS Medicaid is making important changes to the coverage of blood glucose testing supplies, aligning with Medicare coverage criteria, which can be found in the Centers for Medicare & Medicaid Services (CMS) Medicare Coverage of Diabetes Supplies fact sheet. This update is designed to promote effective testing habits to support individuals managing their diabetes. Changes to the supply limits for test strips and lancets and the implications for pharmacies and healthcare providers, are explained below.

Overview of the New NYS Medicaid Policy

Effective October 1, 2024, the NYS Medicaid blood glucose testing supply coverage will align with Medicare policies. The new guidelines are as follows:

• NYS Medicaid members using insulin: Individuals requiring insulin for blood glucose management will be eligible to receive up to 300 test strips and 300 lancets every three months.
• NYS Medicaid members not using insulin: Individuals managing their diabetes without insulin will be eligible for an allowance up to 100 test strips and 100 lancets every three months.

Why This Change Matters

Simplifying Access: Aligning NYS Medicaid policies with the latest clinical guidelines simplifies the process for both pharmacies and physicians, ensuring that beneficiaries receive the supplies they need without unnecessary hurdles.

Pharmacies and Practitioners:

Key Actions: To facilitate a smooth transition to the updated policy, NYRx recommends the following actions for pharmacies and health care providers:

• Educate Patients: Patients with diabetes should be informed about their current testing habits. Pharmacy personnel and health care providers should take the initiative to communicate these changes during patient interactions.
• Promote Effective Monitoring: For patients not currently on an adequate testing regimen, pharmacy personnel and health care providers should encourage establishing a regular routine for blood glucose monitoring, emphasizing the importance of being proactive in managing their condition.
• Understand Claims Processing Limitations: NYRx edit "00710" (Procedure/Formulary Code Exceeds Service Limits), located on the NYRx, the Medicaid Pharmacy Program: Top Edit Resource, will be triggered for claims exceeding the above frequency limitations. Providers should verify the prescription directions for use and consult the prescriber, as necessary, on any changes. Frequency/Quantity/Duration amounts over the current criteria may be considered on a case-by-case basis for limited durations. An example of a medical exception to this limitation could be a patient with a diagnosis of gestational diabetes requiring more frequent monitoring for a period of time.

Questions and Additional Information:

• Additional information regarding the new policy changes can be found on the NYRx Preferred Diabetic Supply Program Resource.
• Providers should refer to the CMS Medicare Coverage Database (MCD) Glucose Monitor - Policy Article.
• NYRx coverage and policy questions should be directed to the Medicaid Pharmacy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
• Billing and claims processing questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Upcoming Changes to Billing Requirements for Professional Drug Claims

Effective October 1, 2024, in preparation for changes per the 2024-25 enacted budget for the reimbursement of practitioner administered drugs (PADs), the New York State (NYS) Department of Health (DOH) only pends claims for manual pricing "BR" (By report) for unlisted drug codes. This applies to the following drug codes:

• "J3490" - Unclassified drugs
• "J3590" - Unclassified biologicals
• "J9999" - Not otherwise classified, antineoplastic drugs
• "J7999" - Compounded drug, not otherwise classified

The above drug codes will continue to be billed via paper claim on an Medical Assistance Health Insurance Claim Form (eMedNY 150003 form), and require the submission of a manufacturer invoice showing the acquisition cost of the drug administered, including all discounts, rebates, and incentives, per program policy.

All other PADs with an assigned J code may be billed via an electronic claim format (837P) for the following categories of service (COS) and with date of service (DOS) that is on or after October 1, 2024:

• Physician and Physician Group ("COS 0460" and "COS 0046") - Additional information can be found on the eMedNY "Physician Manual" web page.
• Nurse Practitioner ("COS 0469") - Additional information can be found in the eMedNY "Nurse Practitioner Manual" web page.
• Midwife ("COS 0525") - Additional information can be found on the eMedNY "Midwife Manual" web page.
• Free Standing or Hospital Based Ordered Ambulatory ("COS 0163" for Clinic Based and "COS 0282" for Hospital Based) - Additional information can be found on the eMedNY " Free Standing or Hospital Based Ordered Ambulatory Manual".
• Podiatry Services ("COS 0500") - Additional information can be found on the eMedNY "Podiatry Manual" web page.

Please note: The practitioner is expected to limit the NYS Medicaid claim amount to the actual invoice cost of the drug dosage administered and maintain that documentation.

Paper claims will still be accepted for all J codes and are required for reimbursement of claims that exceed unit maximums or frequency. Additionally, there are still requirements for additional clinical criteria to be met for certain drugs. To learn more about the additional clinical criteria, practitioners should visit the NYS DOH "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page.

Practitioners should refer to the associated eMedNY provider manual web pages linked above, for additional program policy and billing guidance. Providers are encouraged to use electronic claims submission whenever allowed. These changes should ease practitioner burden by decreasing paper claim submission and associated invoice documentation for claims with a DOS on or after October 1, 2024. It also will have a positive effect on the timing of remittance, thus shortening the turnaround time for payment.

Questions and Additional Information:

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

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ePACES Self-Help Guides Available on eMedNY Website

Electronic Provider Assisted Claim Entry System (ePACES) self-help guides are available on the eMedNY website, by selecting "self help" in the upper right-hand corner of the web page. All provided resources have been created to assist ePACES users with a wide variety of topics including claim entry, eligibility determination, prior approval and claim status inquiry.

5010 ePACES Claim Reference Guides

5010 ePACES claim reference guides are available in Professional, Professional Real Time, Dental and Institutional formats, on the eMedNY "Claim Quick Reference Guides" web page. Guides include claim specific screen captures, descriptions of the individual claim entry fields and instructions on how to batch and submit completed claims.

Questions

ePACES enrollment questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Expanded Reimbursement for Adverse Childhood Experiences Screening

This update expands the screening coverage previously published in the Reimbursement for Adverse Childhood Experiences Screening article published in the December 2023 issue of the Medicaid Update. Effective October 1, 2024, for New York State (NYS) Medicaid fee-for-service (FFS), and effective January 1, 2025, for Medicaid Managed Care (MMC), NYS Medicaid is expanding previously issued coverage for Adverse Childhood Experiences (ACEs) screening conducted in primary care settings for children and adolescents up to 21 years of age. This expansion includes adults, 21 years of age to 65 years of age. For adults, 21 years of age to 65 years of age, the screening is limited to once per lifetime. Please note: An annual ACEs screening will continue to be covered for children and adolescents up to 21 years of age, as determined appropriate and medically necessary.

ACEs are strongly related to brain development and a wide range of health problems throughout the lifetime of an individual. ACEs have been associated with chronic conditions in adulthood, such as obesity, cancer, depression, substance misuse as well as early mortality.

NYS Medicaid recommends integrating Positive Childhood Experiences (PCEs)/protective factors into ACEs screening for children and adults. PCEs are protective factors and can mitigate ACEs and promote resiliency. A critically important component of screening includes conversations with the NYS Medicaid member and their caregiver(s) to identify PCEs that can build resilience. PCEs include growing up with the support of adults (e.g., caregiver and/or other adults), at least one good friend, as well as a positive, predictable quality of life in childhood.

ACEs are categorized into three experience groups: abuse, neglect, and household challenges. These include emotional, physical, and sexual abuse; emotional and physical neglect; and household challenges that include a history of exposure to domestic violence, a family member with household substance use disorder, a family member with mental illness, an incarcerated household member, and/or parental separation or divorce.

ACEs screening should take place in the context of trauma-informed care to ensure a safe, empowering environment for the individual. According to Centers for Disease Control and Prevention (CDC) analysis, significant trauma is associated with substantial mental, physical, and social illness and disease. Trauma-informed care enables responsiveness to a history of specific ACEs of the individual by making the appropriate referrals to clinical services, such as mental health counseling, substance use treatment and care for social needs. Screening for ACEs is always voluntary, to minimize the risk of retraumatizing the individual. Parents/caregivers should complete the ACEs screening on behalf of children under 13 years of age.

Screening for ACEs can benefit adult patients by:

• improving clinical assessment, patient education, and treatment planning for chronic health conditions;
• helping providers and patients address behavioral pathways that lead to ACE-related health conditions; and
• validating and empowering patients, especially those who are pregnant or already parents, which may reduce intergenerational transmission of trauma and contribute to improved family health.

Eligible providers are licensed or unlicensed individuals under the supervision of a licensed provider, with training and experience using the screening tools and delivery of trauma-informed care. Providers conducting the screening must use a research-based screening tool to assess the history of exposure to adversity and factors that influence risk for associated negative outcomes of the individual. Providers and practice sites should consider which screening/assessment tool to use, who should administer the tool and how, and which NYS Medicaid members should be screened. NYS Medicaid also recommends integrating screening for protective factors as a component of ACEs screening. Suggested screening tools and guidance are shown below.

Specific ACEs do not need to be recorded; however, identification of the screening tool and positive or negative result must be documented. Following administration, the provider reviews the screen results along with the patient and parent/caregiver history. If the screen is determined to be positive for ACEs, based on provider discretion, the provider must consider the factors that influence the risk of the patient for associated negative outcomes, along with PCEs, and develop a treatment plan in partnership with the patient or parent/caregiver. Medical practices should ensure that they have the capacity to evaluate and treat children and adults who screen positive for ACEs before implementing standardized screening. Providers are expected to make referrals to appropriate resources, such as mental health providers or community-based organizations, for any needs identified or requested as the result of the screening.

MMC Considerations

The billing instructions and fees listed in the chart are specific to NYS Medicaid FFS. For individuals enrolled in MMC, providers should refer to the MMC Plan of the enrollee for implementation details, reimbursement fees, and billing instructions.

Questions and Additional Information:

• NYS Medicaid 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.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan(s) 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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Reminder: Sign Up for eMedNY Training Webinars

eMedNY offers various types of training webinars for providers and their billing staff, which can be accessed via computer and telephone (no travel is necessary). Valuable provider webinars offered include:

• ePACES for: Doula, Dental, Durable Medical Equipment Supplier (DME), Free-Standing and Hospital-Based Clinics, Institutional, Physician, Private Duty Nursing (PDN), Professional Real Time, Transportation and Vision.
• ePACES Dispensing Validation System (DVS) for DME
• eMedNY Website Review
• Medicaid Eligibility Verification System (MEVS)
• Medicaid Revalidation
• New Provider / New Biller
• Pharmacy - New Provider / New Biller
• Provider Enrollment Maintenance Portal - Practitioner

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

Questions regarding training webinars should be directed to the eMedNY Call Center at (800) 343-9000.

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Update to Medicaid Provider Enrollment Revalidation Requirement

In accordance with federal requirements, the revalidation process that was suspended during the public health emergency (PHE) was restarted. Revalidation dates that are published on the Medicaid Enrolled Provider Listing, and those appearing on provider files are estimated dates that may be subject to change based on factors such as a timing lag, updates made to an enrollment file, and the ability of New York State (NYS) to extend the revalidation date for certain providers. When required to revalidate, notification will always be mailed to the correspondence address of the provider that is on file, providing sufficient time to act. Therefore, providers are asked NOT to submit a revalidation package until notified to do so, as this can cause confusion and delays in processing all application types.

Once a revalidation has been submitted, eMedNY or NYS Department of Health (DOH) will contact the provider if more information is needed. Otherwise, nothing more is needed from the provider. Upon successful processing of the revalidation, the provider will be sent notification of such. Providers can continue to submit claims while the revalidation is awaiting processing.

Providers must ensure their enrollment file is kept up to date to receive important notifications about their enrollment. If an address update is needed, most practitioners can complete that update quickly and easily on the eMedNY "Provider Enrollment Maintenance Portal for Practitioners" web page. All other provider types should complete a Change of Address Form, provided on the eMedNY "Change of Address for Enrolled Providers" web page. Providers are asked to mail the form to eMedNY for processing. To determine if the provider type can submit transactions via the Maintenance Portal, providers should use the eMedNY "Provider Enrollment Portal COS/FORM Look Up Tool" web page.

Questions

Questions regarding the revalidation process should be directed to eMedNY Call Center at (800) 343-9000.

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Medication Synchronization Program Implementation

Effective October 1, 2024, NYRx, the New York State (NYS) Medicaid Pharmacy program, accommodates a point-of-service (POS) indicator when refilling prescriptions for the purpose of Medication Synchronization. The Medication Synchronization program is designed to streamline the medication management process for NYS Medicaid members. Medication synchronization is intended to improve adherence to medication regimens by aligning prescription refills, so that maintenance medications and non-controlled substances are filled on the same day each month.

Medication Synchronization Program Overview

The Medication Synchronization program allows for the synchronization of multiple prescriptions, enabling patients to pick up their medications on a single day each month. This is particularly beneficial for patients who manage multiple conditions, reducing the number of trips to the pharmacy and improving adherence. Pharmacy providers should work with practitioners and patients to determine an effective begin date, to minimize excess supply.

Limitation

All NYS Medicaid beneficiaries are eligible for one synchronization of a specific maintenance medication, per calendar year. This can be systematically applied by utilizing the claim submission process, as described above.

Questions and Additional Information:

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

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Vaccine Billing Update for Pharmacies: Notice of Upcoming Transition

NYRx, the Medicaid Pharmacy program, will expand vaccine billing procedures during the 2024-25 flu season. This change includes the ability to bill by National Drug Code (NDC) for pharmacy categories of service (COS) "0441" and "0442", transitioning from the use of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes.

How Transition Affects Pharmacy Providers

Billing Transition:

• All vaccine claims, when administered in pharmacy settings, will now utilize NDCs in addition to accommodating a single transaction to include administration fee. This change is in compliance with industry standards and new initiatives to modernize the billing process and enhance accuracy in vaccine administration record-keeping.
• Current billing procedures will be kept in place temporarily.

Understanding NDCs:

• NDCs are unique identifiers assigned to medications, including vaccines, that provide specific information about the product, such as the manufacturer, strength, and dosage form. This change will improve the ability to track vaccine distribution and utilization more effectively.
• Utilization of NDC for vaccine billing will standardize reimbursement rates, ensuring up-to-date fees.

Impacted Vaccines

This transition will apply to all pharmacist-administered vaccines. Additional detail can be found in the guides located on the NYS DOH "Pharmacists as Immunizers" web page. Current procedures for all other providers times will be unaffected.

Questions and Additional Information

For questions and additional information regarding this policy, providers should contact NYRx by email at NYRx@health.ny.gov or by telephone at (518) 486-3209.

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Reminder: NYRx Allows 90-Day Prescribing for Most Maintenance Medications and Over the Counter Drugs

NYRx, the Medicaid Pharmacy program, would like to remind stakeholders, including prescribers, pharmacies, NYS Medicaid members, and caregivers that 90-day supplies of most maintenance medications and over the counter (OTC) drugs are covered by NYRx. This benefit applies, but is not limited to, medications prescribed to treat hypertension, diabetes, cholesterol, depression, mild pain, asthma, and chronic obstructive pulmonary disease (COPD).

Ninety-day supplies offer numerous benefits:

• Patient benefits - Cost savings with fewer copays, convenience of fewer trips to the pharmacy, improved medication adherence, and reduced risk of missing refills.
• Prescriber benefits - Increased patient adherence equals easier monitoring, reduced administrative burden, increased patient satisfaction, and a more streamlined process for chronic disease management.
• Pharmacy benefits - Increased patient adherence, improved operational efficiency leading to more time for additional services such as immunizations, medication therapy management (MTM), and enhanced customer satisfaction, resulting in a stronger patient-pharmacy relationship.

Prescribers should consider writing for a 90-day supply and pharmacies should work with prescribers to switch to a 90-day supply once it is determined the patient is on a stable dose of a maintenance medication or OTC drug.

Questions and Additional Information

For questions and additional information regarding this policy, providers and prescribers should contact NYRx by email at NYRx@health.ny.gov or by telephone at (518) 486-3209.

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NYRx, the Medicaid Pharmacy Program, Clinical Call Center Name Change

Effective October 1, 2024, Magellan Medicaid Administration, LLC. changed its name to Prime Therapeutics State Government Solutions, LLC. The vendor will continue to operate as the clinical call center for NYRx, the New York State (NYS) Medicaid Pharmacy program. The clinical call center handles all pharmacy prior authorization (PA) requests from NYS Medicaid providers. There are no changes to procedural operations or services provided.

The clinical call center hours and contact information remains the same. NYS Medicaid providers can continue to contact the clinical call center at (877) 309-9493 or visit the Magellan Medicaid Administration, LLC. "NYRx, the Medicaid Pharmacy Program" homepage. The clinical call center is available 24 hours per day, seven days per week. NYRx is updating the NYS Department of Health (DOH) web pages and resources to reflect the name change.

Questions

Questions regarding this change should be directed to the NYRx at NYRx@health.ny.gov.

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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

The Medicaid Update is a monthly publication of the New York State Department of Health.