New York State Medicaid Update - November 2024 Volume 40 - Number 12

In this issue …

Dental Benefit Expansion of Criteria for Silver Diamine Fluoride

"D1354" (application of caries arresting medicament) has previously been available to New York State (NYS) Medicaid members zero to 20 years of age and those individuals 21 years of age and older with a Restriction Exception code of "RE "81" (TBI Eligible) or "RE 95" [Office For People With Developmental Disabilities (OPWDD)/Managed Care Exemption) for conservative treatment of an active, non-symptomatic carious lesion in the dental setting.

Effective January 1, 2025, for NYS Medicaid fee-for-service (FFS) members and Medicaid Managed Care (MMC) enrollees, "D1354" application of caries arresting medicament is a covered service for all NYS Medicaid members, for conservative treatment of an active, non-symptomatic carious lesion in the dental setting. "D1354" is now reimbursable for topical application of silver diamine fluoride, without mechanical removal of sound tooth structure, regardless of the age of the NYS Medicaid member.

Clinical criteria for the use of silver diamine fluoride:

  • Stabilize non-symptomatic teeth with active carious lesion and no pulpal exposure.
  • Moderate-to-high caries risk (e.g., xerostomia, severe early childhood caries).
  • Treatment challenged by behavioral or medical management.
  • Difficult to treat carious lesions.

Criteria for the reimbursement of silver diamine fluoride:

  • Covered two times per tooth within a twelve-month period, with a total of four times per lifetime of the tooth.
  • Covered with topical application of fluoride ("D1206" or "D1208") when they are performed on the same date of service (DOS) if "D1354" is being used to treat caries and "D1206" or "D1208" is being used to prevent caries.
  • Silver diamine fluoride may be applied to five teeth on the same DOS with more teeth considered in exceptional circumstances. Documentation supporting necessity must be submitted with the claim.
  • Caries arresting medicament is not reimbursable when used as a base for a final restoration.

Providers are required to fully disclose the risks and benefits of silver diamine fluoride use and to discuss treatment alternatives where appropriate. Written consent is required. Providers should refer to the MMC Plan of the individual for implementation details, reimbursement fees and billing instructions.

Current Dental Terminology (CDT) Code Billed By Description NYS Medicaid Rate
D1354 Dentist "D1354" (Application of caries arresting medicament, per tooth)

Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or inhibiting medicament and without mechanical removal of sound tooth structure. Limited to silver diamine fluoride.		 $15.15

Questions and Additional Information:

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Reminder: Vaccines for New York State Medicaid Members Residing in a Long-Term Care Facility or an Assisted Living Program

This article serves to remind and clarify the responsible party for payment of vaccines for New York State (NYS) Medicaid members residing in either a Long-Term Care (LTC) facility or an Assisted Living Program (ALP). As per the June 2011 Nursing Homes/Residential Health Care Facilities Medicaid Prescription Drug Carve-Out Special Edition issue of the Medicaid Update, vaccines, physician administered drugs, over the counter (OTC) drugs, durable medical equipment (DME) and medical supplies are the responsibility of the residential health care facility, also known as a or LTC nursing home facility or an ALP.

Pharmacy claims for items that are the responsibility of the LTC or ALP, including vaccines, will be subject to the following edits:

Edit Number Edit Description National Council for Prescription Drug Programs (NCPDP) Reject Response Additional Notes
01493 Pharmacy Service Included in Facility Rate (in-State) "70" [National Drug Code (NDC) not covered]

Please note: Additional MEVS Denial Code "325" Pharmacy Service Included in in-State Facility Rate		 NYS Medicaid members in an Office for People with Developmental Disabilities (OPWDD) residential health care facility, Category of Service (COS) "0384" (LTC: ICF/Developmentally Disabled) are exempt from this edit.
00867 Pharmacy Service Included in Facility Rate (out-of-state) "85" (Claim not processed)

Please note: Additional MEVS Denial Code "325" Pharmacy Service Included in out-of-State Facility Rate		 N/A
01208 ALP Recipient/Service Included in Per Diem "70" (NDC not covered) N/A

*The Medicaid Eligibility Verification System (MEVS) Denial Code for a transaction is returned within the Additional Message field (526-FQ) and indicates the MEVS error for rejected transactions. Providers should refer to the eMedNY "ProDUR-ECCA D.0 Provider Manual" web page.

NYS Medicaid members who reside in an LTC or an ALP can be identified by a Recipient Restriction/Exception (RR/E) code of "NH" or "AL", respectively, in the eMedNY eligibility verification response. Medicaid Managed Care (MMC) enrollees who reside in a LTC or ALP may alternatively be identified by an R/E code of "N1" [Regular Nursing home (NH)], "N2" (AIDS NH), "N3" (Neuro-Behavioral NH), "N4" (Traumatic Brain Injury (TBI) NH], "N5" (Ventilator Dependent), "N6" (NH-any type), or AL (Assisted Living). Information on how to perform a eligibility verification transaction can be found in the eMedNY Medicaid Eligibility Verification System (MEVS) and Dispensing Validation System (DVS) Provider Manual.

Policy manuals related to LTC and ALP:

Questions:

  • Questions regarding this guidance should be directed to NYRx@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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Coverage of Hypoglossal Nerve Stimulators, Effective January 2025

Effective January 1, 2025, the New York State (NYS) Medicaid program will begin coverage for Hypoglossal Nerve Stimulator insertion and maintenance under Current Procedural Terminology (CPT) codes "64582" through "64584". Hypoglossal Nerve Stimulation (HGNS) coverage will be available through Medicaid Managed Care (MMC) Plans, effective March 1, 2025.

HGNS is a treatment for Obstructive Sleep Apnea (OSA) for individuals who have difficulty tolerating positive airway pressure (PAP) therapy as a treatment modality or have failed PAP therapy.

Medicaid Fee-for-Service Billing:

  • "64582" – Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array.
  • "64583" – Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator.
  • "64584" – Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal array respiratory sensor electrode or electrode array.

These services are to be performed only for the following conditions:

  • Individuals 13 years of age through 17 years of age with Down Syndrome and a diagnosis of moderate to severe OSA with inability to tolerate PAP therapy or has failed PAP therapy.
  • Individuals 18 years of age and over with a diagnosis of moderate to severe OSA and inability to tolerate PAP therapy or has failed PAP therapy.

MMC Plan Billing

For individuals enrolled in MMC Plans, providers should check with the MMC Plan of the enrollee for implementation details, reimbursement fees and billing instructions. 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.

Questions

NYS Medicaid fee-for-service coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by email at FFSMedicaidPolicy@health.ny.gov.

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Reminder: Coordination of Benefits Billing Protocols for Providers; New York State Medicaid is the Payer of Last Resort

Providers are reminded that New York State (NYS) Medicaid claims involving third-party liability must include the appropriate Claim Adjustment Reason Code (CARC) from the primary insurance. CARCs are essential for NYS Medicaid to accurately process claims and determine the correct payment amount. Without the correct CARC, claims may be miscalculated, potentially resulting in NYS Medicaid overpayments or underpayments.

Requirement to Bill Primary Insurance, Even If Not Enrolled

Providers who are not enrolled with a primary insurance payer must still attempt to submit the claim to that primary insurer before billing NYS Medicaid. This process is crucial for NYS Medicaid as payer of last resort and ensures compliance with third-party liability rules. A formal denial from the primary insurer serves as required documentation to support the NYS Medicaid claim and provides a clear audit trail.

If the primary payer issues a CARC with the denial, providers should include this code in their electronic submission to NYS Medicaid, as CARCs are essential for accurate claims processing and helps prevent incorrect payment. If the primary payer will not accept or adjudicate a claim from a non-participating provider, the provider is required to retain clear evidence that the claim submission was first attempted with the primary payer.

Handling Zero-Fill Claims

For any claim submitted to NYS Medicaid as a zero fill, the provider must retain documentation that clearly demonstrates the claim was first submitted to the primary payer. This documentation is essential to confirm that all other payment sources were exhausted before billing NYS Medicaid, which aligns with the NYS Medicaid payer-of-last-resort policy.

Providers must maintain documentation demonstrating that the services rendered are a non-covered benefit by the primary payer. Acceptable documentation includes a claim denial issued within the calendar/benefit year of the claim, verifying that the services are not within the scope of the commercial payer coverage. This documentation may be required for submission to NYS Department of Health to ensure proper processing and payment of claims that were zero-filled. An exception is made for services statutorily not covered by Medicare; in such cases, the provider may bill NYS Medicaid directly without requiring prior submission to Medicare to obtain a claim denial.

Provider Responsibilities:

  1. Identify other payers: Providers must identify all other potential payers for services rendered. This includes, but is not limited to; Medicare, commercial/third-party insurance, and/or workers' compensation.
  2. Bill all prior payers: Providers must bill all identified prior payers and exhaust all available coverage options before submitting a claim to NYS Medicaid. Documentation of these efforts must be maintained and made available upon request.
  3. Submit corrected claims: If payments are received from other payers after NYS Medicaid has reimbursed a claim, providers are required to submit corrected claims to NYS Medicaid and refund any overpayments.

To ensure compliance with NYS Medicaid billing policies, providers should regularly review and update their billing practices This includes periodically checking for any changes in statutory non-covered services to confirm that all available coverage options have been fully utilized before submitting claims to NYS Medicaid. Providers should review, verify, and update any non-coverage information at least annually or whenever significant payer policy changes occur. This process supports the role NYS Medicaid has as the payer of last resort by ensuring that only non-covered services are billed to NYS Medicaid.

Questions and Additional Information:

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NY State of Health Offers Affordable Health Insurance Options During 2024 Open Enrollment

The 2025 Open Enrollment Period (OEP) for NY State of Health, the Official Health Plan Marketplace (Marketplace), kicked off on November 1, 2024. New Yorkers seeking to enroll or renew their health coverage had until December 15, 2024, to complete their enrollment for coverage, beginning January 1, 2025.

NY State of Health is one of the nation's most successful marketplaces offering public and private health insurance programs, including Medicaid, Child Health Plus (CHPlus), Essential Plan (EP) – NY's Basic Health look-alike program, and Qualified Health Plans (QHPs). NY State of Health certifies the health plans that offer coverage, trains, and certifies enrollment assistors who help enroll consumers into coverage and provides customer service assistance to help consumers find the plan that best fits their needs and budget. Since its launch, NY State of Health has helped cut uninsured rates in half, from 10.7 percent in 2013 to 4.8 percent in 2023 – its lowest level on record.

This year's OEP comes on the heels of New York's recently approved Innovation Waiver amendment, which will save an estimated 120,000 QHP enrollees an average of $307 million in 2025. Providers should refer to the State Health Department's NY State of Health Announces Approval of State's Innovation Waiver Amendment in Time for 2025 Enrollment Period press release. The approved waiver amendment provides new cost-sharing subsidies for enrollees and expanded eligibility for all individuals and families with incomes up to 400 percent of the Federal Poverty Line (FPL) – $60,240 for an individual and $124,800 for a family of four.

For 2025, all QHP metal levels have been upgraded. Bronze, Silver, Gold, and Platinum Plans benefits now include $0.00 out-of-pocket costs for most diabetes services, as well as $0.00 out-of-pocket costs for most pregnancy and postpartum health services.

The new Silver Plans – Silver Supreme and Silver Enhanced – offer even more cost savings, including discounted cost-sharing payments, which can include deductibles, copayments, coinsurance, and expanded eligibility for consumers with incomes of 350 percent to 400 percent of the Federal Poverty Level (FPL). Details regarding the 2025 QHP cost savings are located on the NY State of Health "Extra Cost-Savings Through NY State of Health in 2025" web page.

Consumers may also be eligible for expanded EP savings for 2025. For eligible enrollees, EP offers $0.00 monthly premiums, and now consumers with incomes up to 250 percent of the FPL will be eligible. In addition to covering visits to the doctor, hospital care, screenings, prescription medicine, dental and vision benefits, EP benefits now include $0.00 out-of-pocket costs for pregnancy and postpartum services. All copays are removed during pregnancy and postpartum up to one year, and $0.00 out-of-pocket costs for certain services for diabetes. More information on 2025 Cost Savings in Essential Plan is located on the NY State of Health "Extra Cost-Savings Through NY State of Health in 2025" web page.

In addition to the 2025 cost savings initiatives, enhanced tax credits for QHPs remain available through 2025. Initially authorized under the American Rescue Plan Act (ARPA) of 2021 and due to expire at the end of 2025, these tax credits are essential to keeping Marketplace health insurance coverage affordable and providing New Yorkers with additional incentives to take advantage of lowered health care coverage.

More information on how NY State of Health enrollees benefit from the ARPA and the Individual Retirement Accounts, can be found on the NY State of Health "How NY State of Health Enrollees Benefit from the American Rescue Plan and the Inflation Reduction Act" web page. Information on the benefits to New Yorkers of these tax credits, can be found in the NY State of Health Congressional District fact sheets.

Important Dates for 2025 Open Enrollment and Renewals
QHP Renewals:

  • Saturday, November 16, 2024:2025 QHP renewals begin.
  • Sunday, December 15, 2024: Deadline to enroll for January 1, 2025 coverage.
  • Friday, January 31, 2025: Open Enrollment closes for QHPs.

New Applicants:

  • Enroll by Sunday, December 15, 2024, for coverage to begin on Wednesday, January 1, 2025.
  • Enroll beginning Monday, December 16, 2024, and ending, Wednesday, January 15, 2025, for coverage to begin on February 1, 2025.
  • Enroll beginning, Thursday, January 16, 2025, and ending, Friday, January 31, 2025, for coverage to begin on Saturday, March 1, 2025.

Health Insurance Enrollment through NY State of Health:

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NYRx Reimbursement

Effective November 1, 2024, in accordance with the enacted 2024/25 budget and Chapter 57 of the Laws of 2024, the New York State (NYS) Medicaid program has updated the pharmacy reimbursement to:

Drug Type If National Average Drug Acquisition Cost (NADAC) is available, reimburse at: If NADAC is unavailable, reimburse at: Professional Dispensing Fee*
Generics – Multi-Source Lower of NADAC, Federal Upper Limit (FUL), State Maximum Allowable Cost (SMAC) or Usual and Customary (U&C) Lower of Wholesale Acquisition Cost (WAC) – 17.5 percent, FUL, SMAC, or U&C $10.18
Brands – Sole or Multi-Source Lower of NADAC or U&C Lower of WAC or U&C $10.18
Over-the-Counter Drugs (OTCs) Lower of NADAC, FUL, SMAC or U&C Lower of WAC, FUL, SMAC, or U&C $10.18

*Professional Dispensing Fee applies if the drug meets the definition of Covered Outpatient Drug and is not paid at U&C.

Please note: Claims will pay at the U&C pricing of the pharmacy, if lower than drug ingredient cost plus dispensing fee.

OTCs drugs that do not meet the definition of a covered outpatient drug can be identified by utilizing the formulary file search on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page. SMAC prices may be applied when determining the cost of multi- source generic drugs. For questions concerning a SMAC price, providers may complete a NYRx the Medicaid Pharmacy Program State Maximum Allowable Cost (SMAC) Price Research Form.

Questions and Additional Information:

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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.