New York State Medicaid Update - June 2025 Volume 41 - Number 6

In this issue …


New York State Recipient Restriction Program and Health Home Care Management Program Services

Individuals in the Restricted Recipient Program (RRP) may be enrolled in a New York State (NYS) Medicaid Health Home (HH) program, as Health Home Care Management (HHCM) services are excluded from RRP restrictions.

This is a reminder to all NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) providers providing HH program services to NYS Medicaid members who are identified as part of the RRP that HHs are a care management model, authorized under the Affordable Care Act (ACA) that provide intensive care management for NYS Medicaid members that have chronic conditions. HHCM services are not subject to RRP limitations and must be paid by FFS and MMC providers regardless of the RRP status of the NYS Medicaid member.

The RRP is managed by the NYS Office of Medicaid Inspector General (OMIG). The purpose of the RRP is to coordinate medical services and improve quality of care for NYS Medicaid members. Coordination of care reduces the potential over-utilization of health care services and prevents abusive or fraudulent behavior. A restriction is implemented if it is found that a pattern of duplicative, excessive, contraindicated, and/or conflicting health care services, medications, and/or supplies, have been received by the NYS Medicaid member, and/or if a NYS Medicaid member commits fraudulent acts with their benefit card (i.e., forged prescriptions, card loaning, doctor shopping). The RRP may restrict the NYS Medicaid member to care provided or referred by a primary care provider (PCP), inpatient hospital, and/or primary pharmacy. The designated primary physician or primary clinic is responsible for providing all non-emergent medical care to restricted NYS Medicaid members, either directly or by referring them to another medical provider for appropriate services.

HH care managers should familiarize themselves with NYS Medicaid members who are in the RRP as well as their designated RRP providers to work with them to adhere to any restrictions. RRP status and designated RRP provider information can be found in the electronic Provider Assisted Claim Entry System.

Subject to the exceptions below, restrictions may include one or more of the following, or another restriction as specified:

Medical services should be provided by or coordinated by the designated RRP provider. HH care managers should work with the RRP provider and/or pharmacy to ensure that appropriate referrals are made to specialty care as needed. For full regulatory guidance, providers should refer to Title 18 of the NYCRR §360-6.4.

Restriction Exclusions

RRP does not apply to emergency services, opioid treatment program (OTP) services (formerly known as methadone maintenance treatment programs), or inpatient services when a recipient is admitted emergently. Payment will be made for the following medical care and services, which were not rendered, ordered, or referred by a restricted NYS Medicaid member PCP:

For additional guidance, providers can refer to the New York State Medicaid Program Information for All Providers – General Policy document and the NYS OMIG "Frequently Asked Questions for RRP Providers" web page.

Additional Resources:

Questions and Additional Information:

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New York State Department of Health Announces New Advisory Boards: Medicaid Advisory Committee and Beneficiary Advisory Council

The New York State (NYS) Department of Health (DOH) is pleased to share the launch of the two new boards dedicated to the advancement of the NYS Medicaid program. NYS DOH invites NYS residents, providers and caregivers of NYS Medicaid and Children's Health Insurance Program ("Child Health Plus" or CHPlus) members to share their voices and lived experiences by participating on the Medicaid Advisory Committee (MAC) and the Beneficiary Advisory Council (BAC).

This is an exceptional opportunity to assist the NYS Medicaid program and CHPlus in providing access to the highest quality and cost-effective care to members of NYS Medicaid and CHPlus. Committee members will advise and inform policy development in matters related to NYS Medicaid and CHPlus. The MAC members will serve a three-year term, and the BAC members will serve a two-year term.

Additional Information

For additional information regarding the MAC and the BAC, interested participants should visit the NYS DOH "Medicaid Advisory Committee (MAC) and Beneficiary Advisory Council (BAC)" web page or email MAC_BAC@health.ny.gov.

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Notification of Pregnancy to Medicaid Managed Care Plans

Early identification and reporting of pregnant New York State (NYS) Medicaid members allows pregnant individuals to take full advantage of the education, support, resources, and incentives Medicaid Managed Care (MMC) Plans provide throughout the prenatal and postpartum period, which improve quality of care and pregnancy outcomes. Each MMC Plan has a dedicated process for Principal Maternal Care Providers (PMCPs) to utilize when informing the MMC Plan about a pregnant NYS Medicaid member.

Below captures the process of each MMC Plan, effective May 2025. PMCPs are encouraged to notify the health plan of the patient regarding their pregnancy so they can receive additional supports and services.

Managed Care Plan Pregnancy Notification Process
Amida Care Providers should contact the Amida Care provider relations team by email at provider-services@amidacareny.org or by telephone at (800) 556-0674.
Anthem BC BS HealthPlus Providers should complete the notification of pregnancy in the online Interactive Care Reviewer via Availity or fax the Anthem Newborn Notification of Delivery form to Anthem Blue Cross and Blue Shield (Anthem) at (800) 964-3627.
CDPHP Providers should complete and submit a CDPHP High-Risk Pregnancy Referral Form, by email at pregnancy@cdphp.com or by fax at (518) 641-3303.
Emblem Providers should contact care management at (888) 447-0337 (TTY: 711).
Excellus BlueCross BlueShield Providers should complete and submit a Prenatal Incentive Registration and Referral form via the Excellus Provider Portal.
Fidelis Care Providers should complete and submit the Fidelis Care Babycare Program Prenatal Encounter Form.

Providers can contact Fidelis Care by telephone at (888) FIDELIS (1-888-343-3547), or by completing the fields on the Fidelis "Contact Us" web page.
Healthfirst Providers should contact Healthfirst provider services at (888) 801-1660, for assistance
Highmark BC BS Providers should complete the notification of pregnancy in the online Interactive Care Reviewer via Availity or complete and submit a WNY Collaborative Prenatal Care Risk Screening and Referral Form.

Providers should refer to the Highmark "Maternal Child Services" web page, for additional information.
Independent Health Providers should contact Independent Health case management by telephone at (716) 635-7822 or by fax at (716) 250-7140.
MetroPlus Health Plan Providers should notify MetroPlus Health of pregnant NYS Medicaid members at healthpromotion@metroplus.org.

Pregnant NYS Medicaid members should contact MetroPlus Health member services at (800) 303-9626 (TTY: 711), Monday to Friday from 8 a.m. to 6 p.m.; and Saturday from 9 a.m. to 5 p.m. Pregnant NYS Medicaid members looking to contact MetroPlus Health during after hours, which include Sundays and holidays, should contact the Medical Answering Service at (800) 442-2560, available 24 hours per day, seven days per week.
Molina Healthcare Providers should complete and submit the Molina Healthcare Pregnancy Notification Report form.
MVP Health Care Providers should complete and submit the MVP Health Care Prenatal Registration Form.
United Healthcare Providers should complete the United Healthcare Obstetrical Risk Assessment Form, as well as the Care Conductor tool found on the One Healthcare ID website.
Univera Healthcare Providers should complete and submit the Excellus Prenatal Incentive Registration and Referral Form.
VNSNY Choice Providers should contact VNSNY Choice provider relations by telephone at (866)-783-0222 or by accessing the VNS Health provider portal.

Questions

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

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New York State Office of the Medicaid Inspector General to Perform Compliance Program Reviews Using a 12-Month Review Period

For newly initiated Compliance Program Reviews (CPR) beginning after July 1, 2025, the New York State (NYS) Office of the Medicaid Inspector General (OMIG) will perform a 12-month review period. CPRs serve to determine whether required providers have adopted, implemented, and maintained an effective compliance program as required by Title 18 of the New York Codes, Rules, and Regulations Part 521. This change will not affect reviews currently being conducted by NYS OMIG.

NYS OMIG notifies required providers of its intent to commence a review of its compliance program by sending a written notification that includes the review period and procedures for completing the review. The required provider is expected to submit a completed module and related documentation within thirty days of the notification NYS OMIG will engage and communicate with the provider throughout the course of review. Providers will receive formal notification of the results of the review completed by NYS OMIG.

Further information regarding the compliance program review process and provider requirements can be found on the NYS OMIG "Compliance" web page. Information regarding potential penalties for providers that do not have a satisfactory compliance program can be found on the NYS OMIG "Compliance Program Guidance" web page.

Questions

Questions regarding compliance program requirements should be directed to the NYS OMIG Bureau of Compliance at compliance@omig.ny.gov.

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Payment Error Rate Measurement Upcoming Request for New York State Medicaid Provider Documentation

The Centers for Medicare and Medicaid Services (CMS) will measure improper payments in the Medicaid and State Child Health Insurance programs under the Payment Error Rate Measurement (PERM) program. New York State (NYS) will be participating in the PERM program for the seventh time (federal fiscal year 2024 being the last time NYS participated). CMS, along with their review contractor and the NYS Office of the Medicaid Inspector General (OMIG), have the authority to collect information under §1902(a)(27) and §2107(b)(1) of the Social Security Act. The Health Insurance Portability and Accountability Act of 1996 statutes and regulations allow for the provision of such information upon request, and the information can be provided without patient consent.

Consistent with previous PERM reviews, the CMS review contractor, in partnership with NYS OMIG, will request documentation from providers for randomly selected claims to perform a medical review. Results of the last cycle showed an estimated error rate of 1.43 percent for NYS, which included the results of the medical review component, compared to a national average of 5.09 percent. NYS OMIG also successfully overturned 104 of the 118 claims (88 percent) originally determined to be in error utilizing records submitted by providers in response to documentation requests.

To ensure that CMS assesses an accurate error rate for the upcoming PERM cycle, NYS is reminding all providers that compliance with medical record requests and timely providing full medical records for the randomly selected claims is required. Failure to provide requested records will result in a determination by CMS of erroneous payment. NYS OMIG will subsequently pursue appropriate action which may include recovery of the payment.

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Update and Reminder: Medicaid Policy on Loss of Records Due to Unforeseen Events

As stated in Title 18 of the New York Codes Rules and Regulations (NYCRR) §504.3, "by enrolling in the Medicaid program, the provider agrees:

  1. To prepare and to maintain contemporaneous records demonstrating its right to receive payment under the medical assistance program and to keep 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 and to furnish such records and information, upon request, to the department, the Secretary of the United States Department of Health and Human Services, the Deputy Attorney General for Medicaid Fraud Control and the New York State Department of Health;
    1. to comply with the rules, regulations and official directives of the department."

Providers whose records have been damaged, lost, or destroyed are required to report that information as soon as practicable, but no later than thirty calendar days after discovery, to the New York State (NYS) Office of the Medicaid Inspector General (OMIG) Bureau of Self-Disclosure. Failure to report such incidents may result in a determination of overpayment, penalties, and/or sanctions. Please note: Loss/destruction/corruption/inaccessibility of electronic records due to data corruption, data breach, theft, change in data vendor, or other issues also subject to this reporting requirement to ensure compliance with regulatory standards.

Providers are required to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting electronic health records, and should have a secure backup system in place to allow recovery of documentation destroyed or lost due to such events or any other cause.

How to Self-Report Damaged, Lost or Destroyed Records

To self-report, providers must complete the Statement of Damaged, Lost or Destroyed Records form, located on the NYS OMIG "Self-Disclosure Submission Information and Instructions" web page, offers the NYS OMIG Hightail Secure Uplink website, for form submission, and all required supporting documentation.

When self-reporting, providers must include the following information:

  • provider NYS Medicaid enrollment information including Medicaid Management Information System number and National Provider Identifier number;
  • provider contact information; and
  • a statement fully explaining the loss, damage or destruction of records including:
    • a complete and full description of the loss/destruction that occurred including when it occurred, as well as how and when it was discovered;
    • a listing of the documents affected including document type, relevant recipients, and dates of service;
    • names and titles of individuals who discovered and documented the loss/destruction;
    • a description of all actions taken to prevent recurrence of the event that caused the loss/destruction; and
    • a complete listing and copies of any reports of the loss/destruction to insurance companies, police agencies, state agencies, or federal organizations including contact information for those entities.

Providers must also notify any other State or local agency of their loss, damage, or destruction as required by those agencies. Please note: In the event of a NYS Medicaid audit or investigation in which sought records were not maintained as required by Title 18 of the NYCRR §504.3, NYS OMIG will evaluate the Statement of Damaged, Lost or Destroyed Records form and determine on a case-by-case basis whether there are mitigating circumstances for missing or damaged documents.

Additional Information:

  • For assistance with submitting the Statement of Damaged, Lost or Destroyed Records form, providers should contact the NYS OMIG Bureau of Self Disclosure at selfdisclosures@omig.ny.gov.
  • Please note: In addition to Title 18 of the §504.3(a), providers may be subject to other record retention requirements, including but not limited to Title 10 of the NYCRR §405.10; Title 18 of the NYCRR §521-1.3(b), located on the NYS OMIG "Laws and Regulations" web page (select Text of Rule and Statements under "Recently Adopted Regulations"); and contractual requirements under the Medicaid Managed Care program.
    • Additionally, providers continue to be subject to any additional record retention requirements outlined in their prior or current contracts with Medicaid Managed Care or Managed Long-Term Care or subcontractors thereof, or with their contracts with the NYS, including retention for 10 years or more, and in the case of a minor, for 10 years after the date of service or three years after majority, whichever occurs later, and except that such periods shall be deemed amended to implement any longer term that shall be required by applicable federal or state law regulation.

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Notice for Upcoming Over-the-Counter Coverage Changes

As part of the commitment to enhancing patient care, NYRx, the New York State (NYS) Medicaid pharmacy program, has recently conducted a thorough review of over-the-counter (OTC) medication utilization and their clinical effectiveness. This review is in response to a recent amendment to NYS Social Services Law §365-a, effective October 1, 2024. These changes are meant to promote the use of safe, effective, and medically necessary Food and Drug Administration-approved non-prescription drugs for NYRx members. During the February 2025 Drug Utilization Review (DUR) Board Meeting, the DUR Board reviewed and approved coverage changes listed below.

Effective August 1, 2025, NYRx will remove the following products from the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page:

  • Gastrointestinal Products: Bismuth subsalicylate
  • Otic Products: Carbamide peroxide
  • Topical Products: Menthol-containing products

Impact on Providers and Patients:

  • Transition to Alternative Therapies: Providers are encouraged to discuss these changes with their patients. Alternative treatment options are available for medically necessary use.
  • Patient Education: NYRx has notified NYS Medicaid members of these changes. Additionally, provider education to patients about these formulary changes is helpful and to discuss safer and more effective alternatives. Providers communication with patients regarding the rationale behind these changes and the benefits of alternative therapies is essential for a smooth transition.
  • Adjusting Prescribing Practices: Given these changes, providers may need to modify their prescribing practices. It is crucial that providers stay informed about which medications remain NYRx-covered as well as consider the most appropriate therapies for patients' needs. Providers should refer to the New York State Department of Health List of Medicaid Reimbursable Drugs, located on the eMedNY "Medicaid Pharmacy List of Reimbursable Drugs" web page.

NYRx is committed to continuously monitoring medication utilization and effectiveness to ensure that the OTC formulary remains aligned with evidence-based practices.

Questions and Additional Information:

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Attention Providers: Disclosure of Ownership and Control Information

Pursuant to Title 18 of the New York Codes Rules and Regulations (NYCRR) §502.5, enrolled providers are required to inform the New York State (NYS) Department of Health (DOH) within 15 days* of any change in direct or indirect ownership of, control interest in, or managing employee of the enrolled provider. Failure to inform the NYS DOH may result in termination of enrollment. NYS Medicaid regulations define ownership as follows:

  • Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
  • Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity.
  • Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency and includes, but is not limited to, laboratory directors and supervising pharmacists.
  • Person with an ownership or control interest means a person or corporation that:
    • has an ownership interest totaling five percent or more in a disclosing entity;
    • has an indirect ownership interest equal to five percent or more in a disclosing entity;
    • has a combination of direct and indirect ownership interests equal to five percent or more in a disclosing entity;
    • owns an interest of five percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five percent of the value of the property or assets of the disclosing entity;
    • is an officer or director of a disclosing entity that is organized as a corporation; or
    • is a partner in a disclosing entity that is organized as a partnership.
  • Changes of ownership must be reported to NYS Medicaid by submitting the Enrollment Form, located on the eMedNY "Provider Enrollment & Maintenance" web page. To choose the appropriate provider type, providers must check the box marked "Change of Ownership" on the Enrollment Form, and submit the required documentation and forms, as listed on the eMedNY website, for the provider type. This includes pharmacy transfers of ownership.
  • Changes to managing employees or those with a control interest, but not to ownership, should be reported by submitting the applicable New York State Medicaid Disclosure Form, as follows:

*Per the NYRx Medicaid Pharmacy Program Manual, located on the eMedNY "Pharmacy Manual" web page, changes in supervising pharmacist must be reported by the pharmacy owner within seven days. In addition, the pharmacy owner must complete and submit a new Supervising Pharmacist Agreement form (eMedNY-409901). The supervising pharmacist must also submit a New York State Affiliation/Disaffiliation Request form (eMedNY-610201). Both the eMedNY-409901 and eMedNY-610201 forms are located on the eMedNY "Provider Enrollment & Maintenance" web page.

Questions

Providers should contact the eMedNY Call Center at (800) 343-9000 for assistance.

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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.
Acting Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs