New York State Medicaid Update - December 2024 Volume 40 - Number 13

In this issue …

• Policy and Billing
  • New York State Medicaid No Longer Accepts Paper Claims for Medicare Health Maintenance Organization (Medicare Advantage or Part C) Copayment and Coinsurance Charges
  • Reminder: Upcoming Changes to Billing Requirements for New York State Medicaid Fee-for-Service Professional Drug Claims
  • Increase in Reimbursement for Article 28 Clinic Providers Delivering Mental Health Services
  • eConsult Expansion: New Reimbursement in an Outpatient Setting
  • Updated Medicaid Practitioner Claiming Requirements for Sterilizations and Hysterectomies for Medicare Health Maintenance Organization (HMO) Enrollees
  • Ambulatory Patient Group Base Rate Enhancement for Article 28 Providers Serving Individuals with Intellectual, Developmental, and Physical Disabilities
  • Timely Postpartum Visit Incentive
  • Homeless Healthcare Services
  • New York State Medicaid Telehealth Policy Manual Update
• All Providers
  • National Core Indicators Aging and Disabilities Adult Consumer Survey
  • New York State Medicaid Evidence Based Benefit Review Advisory Committee Update
  • Health Homes Added to List of Eligible Providers for New York State Medicaid Community Health Worker Services
  • Reminder: Referrals for Applied Behavior Analysis
• Pharmacy
  • Pharmacy Updates to New York State Medicaid Coverage of Coronavirus Disease 2019 and Public Readiness and Emergency Preparedness Act Services
  • Billing and Eligibility Verification Reminders for Pharmacies

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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New York State Medicaid No Longer Accepts Paper Claims for Medicare Health Maintenance Organization (Medicare Advantage or Part C) Copayment and Coinsurance Charges

eMedNY, the New York State (NYS) Medicaid claims processing system, is being updated to enhance claim editing to ensure accurate NYS Medicaid payments for Medicare Health Maintenance Organization (HMO) (Medicare Advantage or Part C) copayment and coinsurance charges. NYS Medicaid is responsible for reimbursing 85 percent of any co-insurance liability along with the full deductible, in accordance with NYS Social Services Law, §367-a.

To be eligible to receive reimbursement, any/all claims submitted to NYS Medicaid after a Medicare HMO that contains any copayment or coinsurance must be submitted electronically using payer code "16" in the coordination of benefits section. Paper submissions for these claims, including those related to institutional services (e.g., hospital outpatient, clinics, emergency departments), professional services (e.g., pharmacy claims via National Council for Prescription Drug Programs), and dental services, are not allowed to be submitted in paper format, and will subsequently be denied.

Providers must ensure all claims comply with the electronic claim submission requirements to avoid claim denials. Failure to comply with these requirements will trigger claim edit "02313" (invalid paper claim with Medicare Advantage Plan as primary payer) to fail. If this occurs, the following message codes will be reported on the provider Electronic Remittance Advice:

• Claim Adjustment Reason Code "16" - Claim/service lacks information or has submission/billing errors.
• Remark Code "N34" - Incorrect claim form/format for this service.
• Health Care Claim Status Code "481" - Claim/submission format is invalid.

Policy Exceptions:

• Ambulance providers and psychologists claiming Medicare HMO copayments and coinsurance are allowed, but not required to, submit claims electronically (paper claims are allowed).
• Providers must submit paper claims to NYS Medicaid with required documentation attached when claiming ‘by report' procedures (Medicare HMO allows/approves $0.00 payment).

Please note: Providers are required to accept the Medicare health plan payment and any NYS Medicaid payment as payment in-full for the service. Individuals may not be billed for any Medicare HMO copayment or coinsurance amount that is not reimbursed by NYS Medicaid. Providers should refer to the Medicare Learning Center Prohibition on Billing Qualified Medicare Beneficiaries Fact Sheet.

For additional information, previous provider communications regarding NYS Medicaid payment of Medicare HMO copayment and coinsurance charges are available on the following communications:

• Change to Medicaid Reimbursement of Medicare Part C Copayment and Coinsurance Liabilities article published in the July 2016 issue of the Medicaid Update;
• Change to Medicaid Reimbursement of Medicare Part C Copayment and Coinsurance Liabilities article published in the August 2016 issue of the Medicaid Update;
• Reminder: Medicare Part C Providers article published in the April 2017 issue of the Medicaid Update;
• eMedNY Important Medicare Part C Reimbursement Changes Effective 6/1/2017 document;
• Reminder to all Providers on Billing Requirements for Medicare Part C Claims That are Submitted to Medicaid for Payment of Patient Responsibility article published in the October 2019 issue of the Medicaid Update;
• Fee-For-Service Reminders from the Bureau of Dental Review article published in the September 2020 issue of the Medicaid Update; and
• Fee-for-Service Dental Claim Submission Guidance When Third-Party Liability Payment article published in the May 2024 issue of the Medicaid Update.

Questions and Additional Information:

• NYS Medicaid fee-for-service (FFS) coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management at (518) 473-2160 or via email at ffsmedicaidpolicy@health.ny.gov.
• NYS Medicaid FFS dental coverage and policy questions should be directed to dental@health.ny.gov.
• NYS Medicaid FFS claims questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Reminder: Upcoming Changes to Billing Requirements for New York State Medicaid Fee-for-Service Professional Drug Claims

Effective October 1, 2024, in preparation for changes per the enacted 2024-25 budget to the reimbursement of practitioner administered drugs (PADs), the New York State (NYS) Department of Health (DOH) has streamlined the process of pending claims for manual pricing "By Report" ("BR").This will the allow the program to focus on drugs with criteria, that are newly Food and Drug Administration-approved or have no assigned Health Common Procedure Code System (HCPCS) code (i.e., "unclassified"). Unclassified codes include, but are not limited to, the following:

• "J3490" - Unclassified drugs
• "J3590" - Unclassified biologicals

The above drug codes will continue to be billed via paper claim on a Medical Assistance Health Insurance Claim Form (eMedNY 150003 form).

A manufacturer invoice is required showing the acquisition cost of the drug administered, including all discounts, rebates, and incentives, per program policy. In addition, providers are required to report the National Drug Code and quantity. Drugs obtained via the 340B program must be identified by appending a UD modifier to the 340B drug line.

Paper claims will still be accepted for HCPCS codes that exceed unit maximums or frequency. Additionally, there are still requirements for other 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.

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

• Physician ("COS 0460")
  • 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" web page.
• 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.

Practitioners should refer to the associated eMedNY provider manual web pages provided above, for additional program policy and billing guidance. It is recommended that providers use electronic claims submission whenever possible. 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 Division of Program Development and Management by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• NYS Medicaid FFS billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Increase in Reimbursement for Article 28 Clinic Providers Delivering Mental Health Services

Effective January 1, 2025, the New York State (NYS) Medicaid fee-for-service (FFS) program will provide enhanced reimbursement for certain mental health services to Article 28 Hospital Outpatient Departments, freestanding Diagnostic and Treatment Centers, and Federally Qualified Health Centers that have opted into the Ambulatory Patient Group (APG) reimbursement methodology. Providers will receive a nine percent enhancement to the APG base rate utilized in calculating the line-level reimbursement for the specific mental health Current Procedural Terminology (CPT) codes, outlined below.

This payment enhancement aims to increase reimbursement for specific mental health services provided in Article 28 clinics, bringing them in line with the reimbursement rates for the same services offered in Office of Mental Health Article 31 clinics. The goal is to align these payments to better support integrated health care and improve the quality of care for individuals with complex health needs. This approach promotes whole person care, addressing both physical and mental health in a more coordinated and comprehensive way.

The enhanced base rate utilized in the line-level payment calculation will only be utilized when an Article 28 rate code (OPD or DTC) is billed in conjunction with one of the following mental health CPT codes: "90791", "90792", "90832", "90833", "90834", "90836", "90837", "90838", "90839", "90840", "90845", "90846", "90847", "90849", "90853", "90863".

Questions and Additional Information:

• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• FFS medical coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.

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eConsult Expansion: New Reimbursement in an Outpatient Setting

Effective January 1, 2025, for New York State (NYS) Medicaid fee-for-service (FFS) providers, and effective March 1, 2025, for Medicaid Managed Care (MMC) Plans, Hospital Outpatient Departments (OPDs), freestanding Diagnostic and Treatment Centers (D&TCs), and Federally Qualified Health Centers (FQHCs) that have opted into the Ambulatory Patient Group (APG) reimbursement methodology, will be eligible for reimbursement of eConsult Current Procedural Terminology (CPT) codes "99451" and "99452" through the APG fee schedule in an outpatient clinic setting.

FFS Billing

An Article 16, Article 28, Article 31, or Article 32 OPD or D&TC may submit an APG claim to NYS Medicaid for eConsult services, provided that either the treating/requesting provider or the consulting provider is an eligible practitioner employed by the clinic. Claims for eConsult services should utilize one of the designated CPT codes referenced below to ensure appropriate billing and reimbursement.

CPT Code	Billed By	Description	Reimbursement Rate
99451	Consultative provider	Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report of the patient's treating/requesting physician or other qualified health care professional, five minutes or more of medical consultative time.	$28.46
99452	Treating/Requesting provider	Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes.	$26.56

Providers should refer to the eConsults article published in the January 2024 issue of the Medicaid Update. Additional information pertaining to dental eConsults can be found in the eConsults in the Dental Setting article published in the October 2024 issue of the Medicaid Update.

Questions and Additional Information:

• NYS Medicaid FFS billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• NYS Medicaid FFS telehealth coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at telehealth.policy@health.ny.gov.
• MMC enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee. MMC Plan contact and plan directory information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

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Updated Medicaid Practitioner Claiming Requirements for Sterilizations and Hysterectomies for Medicare Health Maintenance Organization (HMO) Enrollees

This update applies to cases when Medicare HMO (Health Maintenance Organization) [Medicare Advantage, Medicare Managed Care (MMC), or Medicare Part C] is the primary payer to New York State (NYS) Medicaid. The NYS Department of Health (DOH) is enhancing eMedNY claim processing logic to ensure proper NYS Medicaid payment of Medicare HMO copayment charges. The maximum NYS Medicaid reimbursement of the Medicare HMO copayment or coinsurance is 85 percent of the copayment or coinsurance charge. Claims must be filed electronically to receive proper payment.

The Sterilization Consent Form (LDSS-3134), located on the NYS DOH "Local Districts Social Service Forms" web page, must be completed for each sterilization procedure. Additionally, the Acknowledgment of Receipt of Hysterectomy Information form (LDSS-3113), located on the NYS DOH "Local Districts Social Service Forms" web page, must be completed for each hysterectomy procedure. Both forms are available in English and Spanish versions (LDSS-3134s and LDSS-3113s).

Effective immediately, professional claims for sterilizations and hysterectomies must be submitted electronically when the individual has Medicare HMO and NYS Medicaid. Practitioners will no longer be allowed to submit these claims and the supporting forms on paper.

Practitioners submitting claims electronically must maintain a copy of the completed Sterilization Consent Form (LDSS-3134) or Acknowledgement of Receipt of Hysterectomy Information form (LDSS-3113) in their files. Claims for sterilizations and hysterectomies must still be submitted on paper with a copy of the supporting consent or acknowledgment form for any primary NYS Medicaid or secondary NYS Medicaid claims not involving a Medicare HMO.

Questions:

• NYS Medicaid fee-for-service (FFS) coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at maternalandchild.healthpolicy@health.ny.gov.
• NYS Medicaid FFS claims questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Ambulatory Patient Group Base Rate Enhancement for Article 28 Providers Serving Individuals with Intellectual, Developmental, and Physical Disabilities

In accordance with the fiscal year 2025 enacted state budget, the New York State (NYS) Department of Health (DOH) increased the Ambulatory Patient Group rates for providers licensed under Article 28 of the Public Health Law (PHL) that serve individuals with intellectual and/or developmental disabilities to 150 percent of the current general clinic base rate. Effective October 1, 2024, these rates apply for all services delivered to NYS Medicaid members with RE code "95"and "81" on the NYS Medicaid file. These enhanced rates are reflective of the additional staff and time needed to serve more complex individuals and are intended to expand access to primary care services and improve health care outcomes.

Please note: NYS DOH will also be increasing the rates for providers licensed under Article 28 of the PHL, serving individuals with physical disabilities. A new RE code, "PD", will be established to identify the physical disability population. NYS DOH has submitted a State Plan Amendment to the Centers for Medicare and Medicaid Services (CMS) and is awaiting approval. Increased rates for providers, billing guidance, and additional information will be forthcoming once CMS approval is obtained.

Questions

Questions should be directed to FFSMedicaidPolicy@health.ny.gov.

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Timely Postpartum Visit Incentive

The New York State (NYS) Medicaid program has received approval from the Centers for Medicare & Medicaid Services (CMS) to provide an additional payment to the current NYS Medicaid reimbursement for comprehensive, timely postpartum visits provided to Medicaid Managed Care (MMC) enrollees. This incentive payment will apply to postpartum visits for deliveries that occurred from July 1, 2024, through March 31, 2025 (with the potential to extend the incentive through June 30, 2026).

Providers who deliver a person-centered comprehensive postpartum visit as outlined by the American College of Obstetricians and Gynecologists clinical guidelines, including a postpartum depression screen, to NYS Medicaid members within 12 weeks of the date of delivery will receive an additional payment of $208.55. Obstetrician/gynecologists, certified nurse midwives, family practice providers, and clinics that provide perinatal services are eligible to receive the incentive. One incentive payment is available per member/delivery combination.

If billing the bundled/global procedure codes ("59400", "59410", "59510", "59515", "59610", "59614", "59618", "59622", "59426", and "59425"), providers must submit a claim for the postpartum visit with Category II Current Procedural Terminology code "0503F", as well as a $0.00 charge for MMC, to be considered for the incentive payment. For the initial announcement and additional information on this direction, providers should refer to the Submission of Prenatal and Postpartum Service Claims for Each Pregnancy Related Visit article published in the June 2024 issue of the Medicaid Update.

Earned payments will be distributed following claim reconciliation to confirm a postpartum visit that meets the guidelines stated above was performed, based on the dates provided in the table below. Providers will receive payment from contracted Managed Care Organizations within six months following the claims runout end date to allow time to complete the reconciliation and process the payments.

Performance Year One (July 2024 to June 2025 )
Date of Delivery	Comprehensive Postpartum Visit Period End Date	Claims Runout End Date
July 1, 2024 to September 30, 2024	December 23, 2024	June 23, 2025
October 1, 2024 to December 31, 2024	March 25, 2025	September 25, 2025
January 1, 2025 to March 31, 2025	June 23, 2025	December 23, 2025
April 1, 2025 to June 30, 2025	September 22, 2025	March 22, 2026

Questions

Questions should be directed to MaternalandChild.HealthPolicy@health.ny.gov.

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Homeless Healthcare Services

The New York State (NYS) Department of Health (DOH) Office of Health Insurance Programs (OHIP) is implementing new policy and billing guidance for providing services to NYS Medicaid members experiencing homelessness. Effective February 1, 2025, NYS Medicaid Managed Care (MMC) Plans must reimburse credentialed, in-network Homeless Healthcare providers for primary care services provided to an MMC Plan enrollee experiencing homelessness, regardless of whether the provider is the assigned primary care provider (PCP) of the enrollee. The MMC Plan must reimburse such services at the agreed upon contracted PCP rates.

For purposes of the policy and billing guidance, Homeless Healthcare provider includes any licensed medical provider or any licensed dental provider who conducts patient visits with homeless individuals in a sheltered or unsheltered location. Please note: Medical providers, who are not physicians, must be supervised by a physician practitioner who is knowledgeable about health care for individuals experiencing homelessness, and all providers must only deliver services within the scope of their professional license.

Primary care services eligible for reimbursement may include, but are not limited to:

• physical exams;
• diagnosis and treatment of acute medical conditions;
• routine management and treatment of chronic conditions (e.g., diabetes, hypertension, etc.);
• prescriptions provided for minor problems, acute problems and chronic conditions;
• laboratory testing;
• immunizations;
• reproductive health care;
• basic oral health care (e.g., cleaning, simple extractions, fillings and x-rays);
• health care navigation and referrals to specialists including behavioral health, as needed; and
• basic care coordination and social services referrals.

Additional Information and Questions:

• For additional details, medical providers should refer to the Homeless Healthcare Services - New York State Medicaid Coverage Policy and Billing Guidance for Providing Services to Medicaid Members Experiencing Homelessness.
• Questions may be submitted to SDH@health.ny.gov.

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New York State Medicaid Telehealth Policy Manual Update

On December 20, 2024, the New York State (NYS) Medicaid program published Version 2024-V2 of the Telehealth Policy Manual - New York State Medicaid Fee-for-Service Provider Policy Manual. The information in the manual applies to all NYS Medicaid-enrolled providers and Medicaid Managed Care (MMC) plans, effective immediately. Updates to the manual include:

• Section 4.8: Clarified when audio-only telehealth is appropriate.
• Section 9.6: Edited audio-only billing guidance.
• Section 9.8: Clarified remote patient monitoring (RPM) policy and added guidance for RPM delivered by clinical staff.
• Section 9.10: Updated procedure code for virtual check-ins.
• Section 9.12: Clarified virtual patient education billing guidance for Community Health Worker and Asthma Self-Management Training services.
• Section 9.14: Clarified eConsult policy, added guidance for eConsults in the dental setting, and added guidance for Ambulatory Patient Group reimbursement.
• Section 9.15: Added guidance for Home Sleep Tests.
• Section 9.16: Clarified Article 28 Federally Qualified Health Center billing.
• Section 10.7: Added restriction for doula services via telehealth.
• Section 10.8: Added restriction for shipment of physician administered drugs.

Providers should visit the NYS Department of Health (DOH) "NYS Medicaid Telehealth" web page, to access the manual.

Questions and Additional Information:

• NYS Medicaid fee-for-service (FFS) billing and claims questions should be directed to the eMedNY Call Center at (800) 343-9000.
• NYS Medicaid FFS telehealth coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 473-2160 or by email at telehealth.policy@health.ny.gov.
• MMC enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee.
• MMC Plan contact information and plan directory can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

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National Core Indicators Aging and Disabilities Adult Consumer Survey

New York State (NYS) Department of Health (DOH) is pleased to announce the launch of the National Core Indicators Aging and Disabilities (NCI-AD) Adult Consumer Survey. The NCI-AD Adult Consumer Survey collects NYS Medicaid member responses to better understand the characteristics, health, well-being, and experience of care among adults and people with physical disabilities who receive home and community-based services. NYS DOH and its survey vendor, Knowledge Services, will be surveying over 400 people across NYS through spring 2025.

Questions and Additional Information:

• Questions regarding the initiative should be directed to NYS DOH at HCBSQM@health.ny.gov or Knowledge Services at (866) 228-5859.
• For additional information regarding the initiative, providers should refer to the NYS DOH "NCI-AD Adult Consumer Survey FAQs" web page.

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New York State Medicaid Evidence Based Benefit Review Advisory Committee Update

On November 21, 2024, the New York State (NYS) Medicaid Evidence Based Benefit Review Advisory Committee (EBBRAC) convened its second meeting of 2024. EBBRAC was established in 2015, pursuant to Chapter 57, Part B, §46-a of the Laws of 2015 as Social Services Law §365-d, to make recommendations to the NYS Department of Health regarding NYS Medicaid coverage of health technologies and services. During the meeting, EBBRAC reviewed the following:

• Digital health technologies (definitions, regulatory framework, and considerations);
• Canvas DX™ as a diagnostic aid for autism in young children; and
• Freespira® for panic disorder and posttraumatic stress.

Meeting agendas, notes and archived webcasts are available on the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page. The next EBBRAC meeting will be held on April 10, 2025. Providers should refer to the NYS DOH Medicaid "Evidence Based Benefit Review Advisory Committee (EBBRAC)" web page, for information regarding upcoming meetings, meeting agendas, calls for public comments, as well as information on EBBRAC composition and recommendations.

Questions

Questions regarding EBBRAC should be directed to EBBRAC@health.ny.gov.

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Health Homes Added to List of Eligible Providers for New York State Medicaid Community Health Worker Services

Effective January 1, 2025, for New York State (NYS) Medicaid fee-for-service (FFS), and effective April 1, 2025, for Medicaid Managed Care (MMC), Health Home (HH) is added to the list of eligible providers for community health worker (CHW) services.

CHW services include health advocacy, health education, and health navigation supports aimed at improving health outcomes and overall health literacy and preventing the development of adverse health conditions, injury, illness, or the progression thereof. A CHW is a public health worker, not otherwise recognized as a licensed or certified NYS Medicaid provider type. At this time, CHWs are not an enrollable provider type, and their services are billed by a NYS Medicaid-enrolled qualified health care practitioner who is responsible for supervising the services rendered by the CHW.

CHW services are covered for the following NYS Medicaid members:

• children under 21 years of age;
• pregnant and postpartum individuals during pregnancy, and up to 12 months after pregnancy ends, regardless of the pregnancy outcome;
• adults with chronic conditions;
• individuals with justice system involvement within the past 12 months;
• individuals with an unmet health-related social need in the domains of housing, nutrition, transportation, or interpersonal safety, which have been identified through screening using the Centers for Medicare & Medicaid Services Accountable Health Communities Health-Related Social Needs Screening Tool; and
• individuals who have been exposed to community violence or have a personal history of injury sustained as a result of an act of community violence, or who are at an elevated risk of violent injury or retaliation resulting from another act of community violence.

Please note:

• CHW services are not covered for NYS Medicaid members enrolled in a HH program, a HH Care Coordination Organization, or who receive care coordination services through a certified community behavioral health clinic or Assertive Community Treatment when receiving care management services from these providers. HHs may be reimbursed for the provision of CHW services when provided to NYS Medicaid members before or after they receive other care management services from these entities and not when they are enrolled in a HH program.
• For a HH to bill for community violence prevention services, the HH must meet the training requirements in sections 11.1 and 11.2 of the Community Health Worker Services Manual - eMedNY New York State Medicaid Provider Policy Manual.

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 Division of Program Development and Management by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• NYS Medicaid FFS HH billing questions may be submitted to the NYS Medicaid HH Provider Line by telephone at (518) 473-5569 or by email at healthhomes@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.

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Reminder: Referrals for Applied Behavior Analysis

The New York State (NYS) Medicaid fee-for-service (FFS) program requires that NYS Medicaid members are referred for Applied Behavior Analysis (ABA) services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant.

Referrals for ABA services are valid for no more than two years and should include the following:

• patient age;
• Autism Spectrum Disorder (ASD) or Rett Syndrome diagnosis;
• date of initial diagnosis;
• co-morbid diagnosis (if applicable);
• symptom severity level/level of support (if referral is from an ASD-diagnosing provider);
• statement the patient needs ABA services; and
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Diagnostic Checklist, for ASD diagnoses.

Please note: The National Provider Identifier of the ordering/referring provider must be included on all claims for ABA services submitted to NYS Medicaid FFS, in order for the claim to pay.

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 Division of Program Development and Management by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.

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Pharmacy Updates to New York State Medicaid Coverage of Coronavirus Disease 2019 and Public Readiness and Emergency Preparedness Act Services

The following guidance applies to coronavirus disease 2019 (COVID-19)-related services delivered to New York State (NYS) Medicaid fee-for-service (FFS) members and Medicaid Managed Care (MMC) enrollees regarding the Public Readiness and Emergency Preparedness (PREP) Act extension to December 31, 2029. This communication updates the information provided in the September 2024 Updates to New York State Medicaid Coverage of Coronavirus Disease 2019 Services Special Edition issue of the Medicaid Update.

NYRx, the NYS Medicaid Pharmacy program, will continue to provide coverage until further notice or December 31, 2029, for pharmacist-ordered and administered:

• COVID-19 vaccines to eligible NYS Medicaid members three years of age and older, and
• COVID-19 treatments.

Until further notice or December 31, 2029, non-Vaccines for Children-enrolled pharmacies may continue billing NYRx for COVID-19 vaccines at actual acquisition cost for eligible NYS Medicaid members three years of age to 18 years of age, as per the NYRx, Medicaid Pharmacy Program Pharmacists as Immunizers Fact Sheet. All other federal and state laws and NYS Medicaid regulations apply.

Questions and Additional Information:

• NYRx coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at (518) 483-3209 or by email at NYRx@health.ny.gov.
• NYS Medicaid Pharmacy policy questions should be directed to NYRx@health.ny.gov.

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Billing and Eligibility Verification Reminders for Pharmacies

As previously noted in the January 2023 NYRx Pharmacy Benefit Transition - Part Two Special Edition issue of the Medicaid Update, pharmacies need to bill NYRx, the New York State (NYS) Medicaid Pharmacy program, using the Client Identification Number (CIN), which can be found on the NYS Medicaid Common Benefit Identification Card (CBIC) and on the Medicaid Managed Care (MMC) Plan Identification (ID) card of the enrollee. Pharmacies should ask the NYS Medicaid member for all insurance cards at the point of service (POS) to avoid unnecessary delays in care.

The MMC Plan ID card number contains the CIN, which is unique to NYS Medicaid members and MMC enrollees. This number is used when billing NYRx. The CIN is always represented as an eight-digit code in the form of two alpha - five numeric - one alpha (XX00000X). In some cases, the CIN may be embedded in the MMC Plan ID card number of the MMC enrollee. The CIN can be found on both the MMC Plan ID card and the NYS Medicaid CBIC of the NYS Medicaid member and MMC enrollee. NYS Medicaid members may also contact the NYS Medicaid Consumer Helpline by telephone at (800) 541-2831, to obtain their CIN.

The chart below indicates the CIN format for each MMC Plan ID card. Card samples identifying the CIN location on the MMC Plan ID card can be found on the New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center website.

Eligibility Determination

Pharmacists may use one of the methods in the table provided below, to conduct an eligibility check and/or obtain the CIN of the NYS Medicaid member and MMC enrollee.

Questions and Additional Information:

• Providers with questions regarding ePACES or in need of assistance with billing and performing Medicaid Eligibility Verification System (MEVS) transactions should be directed to the following:
  • Touchtone Telephone Verification System - (800) 997-1111
  • eMedNY Support - (800) 343-9000, Option 2

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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.