Scope of Benefits

Updated: April 7, 2021

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Important:

The FY 2022 Enacted Budget delays the transition of the Medicaid pharmacy benefit by two years, until April 1, 2023.

Pharmacy Transition: The following charts provide additional context and information related to the Department´s implementation of the Pharmacy Transition from managed care to fee-for-service (FFS), effective April 1, 2023.

CHART #1

This chart provides a snapshot of what is changing and what is not in relation to pharmacy services in New York Medicaid´s two delivery systems, managed care and FFS, in the current state (pre-transition) and future state (post-transition).

Pharmacy Services Current State (Pre-Transition) Future State (Post-Transition)
Managed Care Delivery System
  • Pharmacy benefits that are billed on pharmacy claims.
  • Managed Care Plans (MCPs) are responsible for providing these benefits, and this is built into the capitated payment.
  • MCPs will no longer be responsible for those items identified in Chart #2 as being subject to the FFS carve-out; these benefits will be removed from the capitated payment.
  • These claims will be processed under FFS and paid through the eMedNY system.
  • Pharmacy benefits that are billed on medical and institutional claims.
  • Managed Care Plans (MCPs) are responsible for providing these benefits, and this is built into the capitated payment.
  • No change.
FFS Delivery System
  • Pharmacy benefits that are billed on pharmacy claims.
  • Are processed and adjudicated through eMedNY.
  • These claims will be processed under FFS and paid through the eMedNY system.
  • Pharmacy benefits that are billed on medical and institutional claims.
  • Are processed and adjudicated through eMedNY.
  • No change.

CHART #2

This chart provides an inventory of the NYS Medicaid´s outpatient pharmacy benefit, and whether the benefit is subject to the carve-out and whether the managed care plans should also continue to make the benefit available when provided by a non-pharmacy provider.

Pharmacy Benefit Category Sub-Category Subject to the FFS Carve-Out?
(Yes, No)		 MCPs to make available when billed as a medical or institutional claim?
(e.g. outpatient hospital, clinic, physician´s office) *
Outpatient Prescription Drugs included in the Medicaid Pharmacy List of Reimbursable Drugs. (Includes Clotting Factor) N/A Yes Yes
([for drugs that are also practitioner/physician administered (i.e. J-Codes)]
Practitioner/Physician Administered Drugs that are not included in the Medicaid Pharmacy List of Reimbursable Drugs. N/A No Yes
Outpatient Over the Counter (OTC) Drugs included in the Medicaid Pharmacy List of Reimbursable Drugs. N/A Yes No
Vaccines that can be administered by pharmacists** N/A Yes Yes
COVID-19 Diagnostic Testing & Specimen Collection N/A Yes Yes
Supplies as listed in the Pharmacy Procedures & Supply Codes, Manual and categorized below   Yes No
Enteral & Parenteral Nutrition Enteral and Parenteral Nutrition Formula Yes No
Enteral and Parenteral Feeding Supply Kit and Tubing Yes No
Family Planning Condoms and Diaphragms Yes No
Medical/Surgical Supplies Incontinence Care – Under Pads, Diapers, Liners, Catheters and Accessories Yes No
Adhesive Tape/Remover Yes No
Antiseptics Yes No
Commode Accessories- Bed Pans, Urinals, Sitz Baths Yes No
Breast Pumps (except rental of hospital grade pumps) Yes No
Blood Pressure Monitors Yes No
Canes/Crutches and Accessories Yes No
Diabetic Diagnostics and Daily Care- Glucose Testing Supplies, Disposable Insulin Pumps (Omnipod), Continuous Glucose Monitor (CGM), Insulin Syringes, Needles, Pens, Infusion Supplies Yes No
Mastectomy Care - Mastectomy Bras, Breast Prosthesis (except custom prosthesis), Camisoles Yes No
Respiratory/Tracheostomy Care Supplies Yes No
External Urinary Supplies - Drainage Bags and Urethral Clamps Yes No
Ostomy Supplies Yes No
Wound Dressings Yes No
Syringes Yes No
Gloves Yes No
Heat Application/Thermometers/Cold Wraps Yes No
Surgical Stockings, Slings, Splints, Cervical Foam Collars Yes No
  Plastic Strips, Sterile Wood Applicators, Spirometers, Nasal Aspirators Yes No
  Disposable Drug Delivery Systems Yes No
  Sterile Water, Saline, and Dextrose Yes No
Hearing Aid Batteries N/A Yes No
Medical supplies dispensed during a Physician´s Office visit and billed under CPT code 99070:
  • Supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered.
 Examples are: crutches, boots or other starter medical supplies. Yes No
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies as listed in the Durable Medical Equipment, Prosthetics and Supplies Manual and categorized within Appendix A. N/A No Yes
Low Protein Medical Foods (LPMF) billed by the medical provider under Ordered Ambulatory Procedure Code S9435. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies as listed in the Durable Medical Equipment, Prosthetics and Supplies Manual and categorized within Appendix A. Medical food for inborn errors of metabolism No Yes

* For benefits marked as Yes, MCPs will continue to pay for these benefits for their members when they are not billed by pharmacies.
** New York State Education laws § 6527, 6801, and 6909 permit licensed pharmacists, who obtain an additional certification, to administer influenza vaccine to children between the ages of 2 and 18 years of age and to adults 18 years of age and older, and to administer pneumococcal, meningococcal, tetanus, diphtheria, pertussis and herpes zoster vaccinations to adults 18 years of age and older.

Appendix A

This appendix provides a list of Durable Medical Equipment (DME) supplies that are not subject to the carve-out and are found within the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines. Within the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines, sections 4.1, 4.2, and 4.3 are subject to the carve-out while sections 4.4, 4.5, 4.6, and 4.7 will remain the responsibility of the Managed Care Plans. For convenience, the items that will not be subject to the carve-out are categorized and listed below. Please refer the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines for more specific guidance.

Medical/Surgical Supplies
  • Hospital grade breast pump rentals
Durable Medical Equipment
  • Hospital beds and accessories
  • Oxygen systems
  • Respiratory care supplies
  • Ventilators and accessories
  • CPAP/BiPAP devices and accessories
  • Airway clearance devices and accessories
  • Traction equipment
  • Walkers
  • Pediatric gait trainers
  • Wheelchairs and accessories
  • Powered mobility devices
  • Power operated vehicles
  • Miscellaneous Durable Medical Equipment:
    • Paraffin bath unit and wax
    • Apnea monitor and supplieselectrodes, lead wires
    • Replacement battery for external infusion pump
    • Commodes, bath/shower chairs, bathtub/toilet rails, raised toilet seats, tub stools/benches, transfer benches
    • Seat lift mechanisms
    • Automatic external defibrillator garment
    • Vacuum erection system
    • Artificial larynx, batteries, accessories
    • Tracheostomy speaking valve
    • Tracheo-esophageal voice prosthesis and gelatin capsules, voice amplifier
    • Insert for indwelling tracheoesophageal prosthesis (replacement only)
    • Tracheoesophageal puncture dilator (replacement only)
    • Enuresis alarm
    • Phototherapy lights
  • Home standing systems
  • TENS devices (including electrodes, lead wires, batteries), osteogenesis stimulators
  • IV poles, ambulatory infusion pumps
  • External ambulatory infusion pump, insulin
  • Parenteral infusion pumps
  • Hyperbaric oxygen chambers, negative pressure wound therapy
  • Speech generating devices, accessories, and repairs
  • Eye control/eye gaze accessories
  • Servicing, parts, and repairs of Durable Medical Equipment
Orthotics
  • Orthotic devices, additions, procedures, and repairs
Prescription Footwear
  • Orthopedic footwear, additions, transfers, and replacements
  • Diabetic shoes, fitting, and modifications
Prosthetics
  • Prosthetics, procedures, and additions
  • Breast and Hair prosthesis
    • Custom breast prosthesis and mastectomy sleeve (mastectomy bras, camisoles, and non-custom breast prostheses will transition to FFS)
  • Upper extremity elastic supports
  • Lower extremity compression supports
  • Trusses
  • Prosthetic Socks
  • Burn garments