MLTC Policy 19.02

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Office of Health Insurance Programs
Division of Long Term Care

Managed Care Policy 19.02: Clarification of Medicaid provider enrollment provisions for services provided by integrated Medicare/Medicaid Plans (Integrated Plans) through the 21st Century Cures Act

Date of Issuance: July 19, 2019

In May of 2019, the Department sent information to all Medicaid Advantage Plus and Medicaid Advantage Plans (i.e., Integrated Plans) containing a list of approved provider terminations, required pursuant to 42 U.S.C. § 1396u–2(d) as amended by Section 5005(b)(2) of the 21st Century Cures Act. Since then, the Department has received questions regarding the status of certain providers and whether they should be terminated. This policy is being issued to address plan questions and provide further guidance regarding which providers must be terminated from an Integrated Plan´s Medicaid provider network.

Pursuant to federal law and in conformance with CMS´s April 22, 2019 guidance, Integrated Plan network providers must enroll as a Medicaid provider in the New York State Medicaid program in order to remain in an Integrated Plan´s Medicaid provider network.

Provider types that are not enrollable in the New York State Medicaid Program are not subject to this requirement. Providers subject to this requirement may remain in an Integrated Plan´s Medicare provider network regardless of whether they enroll as a Medicaid provider. However, Integrated Plans are responsible for establishing adequate mechanisms to ensure that Medicare–only network providers that are not enrolled Medicaid providers cannot bill the Integrated Plan for benefit package services, other than Medicare cost–sharing, where Medicaid is or could become primary payor. These services are identified in Appendix K–2 of each Integrated Plan´s model contract.

Please note that network adequacy for Medicaid services in an Integrated Plan´s benefit package is based on the number and location of providers in the plan´s Medicaid provider network.

If you have further questions, please contact: Mltc.compliance.reporting@health.ny.gov