GIS 11 MA/024: Medicaid Requirements Regarding Ordering and Referring Physicians

The purpose of this GIS is to inform local departments of social services of the impact of recent federal regulations governing physicians who order services for Medicaid recipients. [42 CFR § 455.410, effective March 25, 2011]

This federal regulation implements Social Security Act §1902(kk)(7). It requires that the State Medicaid agency must require all ordering or referring physicians or other health professionals providing services under the State Plan or under a waiver of the plan to be enrolled as participating providers. As a result, for purposes of the Personal Care Services Program, Personal Emergency Response Services, Consumer Directed Personal Assistance Program, Limited Licensed Home Care Services Agencies and Assisted Living Program, all consumers in receipt of, or applying for, participation in these programs must use participating physicians to sign the physician's order as required. If the physician who examines the consumer and completes and signs required orders is not enrolled in New York State Medicaid, the physician's orders cannot be accepted. This new rule applies when the consumer was eligible for Medicaid when the physician's order was signed. If the physician's order was signed before the consumer became eligible for Medicaid, it may be accepted.

If district staff is unsure as to whether a physician is enrolled, such information can be obtained by contacting the CSC Call Center at 800-343-9000. Any questions regarding the content of this directive can be directed to the district's home care liaison at 518-474-5888.