DOH Medicaid Update February 2006 Vol. 21, No. 2

Office of Medicaid Management
DOH Medicaid Update
February 2006 Vol. 21, No. 2


State of New York
George E. Pataki, Governor

Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management
Brian Wing, Deputy Commissioner


Prescribers, Pharmacists
and Nursing Homes

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We will regularly feature updates on the new Medicare Prescription Drug Benefit during the implementation phase. The following information concerns updates, clarifications, and new information on the Medicare Prescription Drug Program.

Important Information for Patients with Employer/Union Retiree Health Insurance Coverage

Employer/Union Letter

Dual eligibles may receive a letter from their employer or union regarding their health care benefits. This letter states that recipients and their family members enrolled in Medicare Part D may lose their health care benefits provided by their employer or union.

If recipients received this letter, they may disenroll from the Medicare Prescription Drug program by calling:


Recipients must give a copy of this letter to their local Medicaid worker to continue receiving their Medicaid benefits. Certain situations may require the recipient to re-enroll in Part D to continue to receive Medicaid.

Medicare Advantage Plans

Dual eligibles in New York are able to get their Medicare Part D prescription drug coverage through their choice of a free standing Prescription Drug Plan (PDP) that works with traditional Medicare or through a Medicare Advantage Plan.

Medicare Advantage Plans can include:

  • Medicare HMOs,
  • Medicare PPOs, and
  • Medicare Special Needs Plans.

These plans generally provide all Medicare covered health care through the plan. When the coverage includes Medicare Part D prescription drug coverage the plan is called an MA-PD.

On behalf of CMS, Medicare Advantage organizations facilitated enrollment of their full benefit dual eligible members into one of their MA-PD products effective January 1, 2006. Several Medicare Advantage organizations must offer at least one plan with no additional premium or deductibles for drug coverage. Dual eligible enrollees should not have to pay an additional premium cost for drug coverage unless they chose a plan above the benchmark. In this case, beneficiaries may be responsible for an additional premium payment.

A dual eligible recipient in a nursing home who is enrolled in Medicare Advantage Plan that offers Medicare Part D prescription drug coverage as of January 2006 does not have to enroll in a stand alone PDP, as suggested in the January 2006 Medicaid Update. However, if the individual is enrolled in an MA-PD that does not offer the Medicare Part D prescription drug coverage at no additional premium, the individual may be responsible for the premium payment. In such cases, the individual may wish to enroll in another Medicare Advantage plan that offers Part D prescription drug coverage at no additional premium or participate in the original Medicare plan and join a benchmark PDP for their Part D prescription drug coverage.

We apologize for any confusion or misunderstanding that may have resulted from the January Medicaid Update article. For more information about Medicare prescription drug coverage offered by Medicare Advantage Plans call 1-800-MEDICARE or visit at:

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Full benefit dual eligibles who are institutionalized (as defined by CMS) and enrolled in a benchmark Part D plan or a Medicare Advantage-Prescription Drug Plan (PDP or MA-PD) will not be responsible for the payment of deductibles or co-pays, nor will they be subject to a coverage gap in their Part D benefits. However, there are some circumstances where payment may be required. Listed below are the various circumstances that may apply to institutionalized full benefit duals:

  • Individuals who were full benefit duals and institutionalized for a full calendar month as of January 1, 2006 will be auto-enrolled into a PDP or, if in a Medicare Advantage plan that offers a drug plan, into the sponsoring organizations MA-PD. The plan will not require co-pays or deductibles and no coverage gap will apply.
  • For individuals who were full benefit duals prior to institutionalization, and who were subject to co-pays, the plan may continue to charge co-pays until such time as the plan is notified of the individual's institutionalization status. CMS requires that the recipient be institutionalized for a full calendar month before they consider the recipient institutionalized. For example, if the recipient was admitted to the facility December 15, 2005, they would not meet CMS's institutional definition until February 1, 2006. If the State identifies the individual as an institutionalized full benefit dual for past months on their monthly MMA file, the plan will reimburse the individual for any co-pays incurred during those months.
  • For individuals who were enrolled in Part D, but who were not eligible for Medicaid at the time of institutionalization, the plan may continue to charge co-pays, deductibles and costs incurred until such time as the plan is notified of the individual's status as an institutionalized full benefit dual. If the state identifies the individual as an institutionalized full benefit dual for past months on their monthly MMA file, the plan will reimburse the individual for co-pays, deductibles and costs incurred during those months.
  • Individuals who qualify for Part D but are not enrolled in a plan, and are not Medicaid eligible at the time of institutionalization, will be fully responsible for their drug costs. Note that individuals can join a plan prior to the time their Medicaid eligibility is determined. In addition, the individual, or someone on their behalf, can apply to the SSA for the low income subsidy (LIS). Plan enrollment and eligibility for the LIS will likely occur before their Medicaid eligibility is determined. Therefore, once the individual is in a PDP or MA-PD and is determined to be LIS eligible, the plan will be responsible for drug cost as of the effective date of the enrollment and the individual will pay no premium, deductibles, and reduced co-payments. Once the individual is determined to be Medicaid eligible, there will be no out of pocket drug costs for the recipient (as long as institutionalized for a full calendar month).

Medicare Reminders

  • Dual eligible individuals enrolled in a benchmark plan should not be charged more than $1 for generic drugs or $3 for brand name drugs.
  • For questions/problems regarding eligibility and plan enrollment, pharmacists may call a dedicated pharmacy eligibility line at 1-866-835-7595.


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Since implementation of the new Medicare prescription drug program, there have been instances of dual recipients being denied their medications or being charged deductibles and excessive co-payment amounts. Steps are being taken by the federal Centers for Medicare and Medicaid Services (CMS) to correct these problems.

If pharmacists experience difficulty with their patients' Medicare plan enrollment, cost sharing, or payment, the following procedures should be followed:

  1. Check for enrollment in a Part D plan, by asking for a plan ID card or other documentation from a Part D plan, or, submit an E1 query.

    If the E1 response is only a telephone number, call that telephone number to obtain the billing information from the plan. Pharmacists can also get information on a beneficiary's enrollment, and on how to contact the plan, by calling Medicare's dedicated pharmacy assistance line (1-866-835-7595), which is available 24/7.

  2. If the individual is enrolled in a plan, but is not being charged the correct dual-eligible co-payment amounts:

    contact the drug plan (which has expedited access for pharmacy requests to adjust co-payments), or, if the situation is urgent and other steps have not worked, contact Medicare's pharmacy assistance line for urgent caseworker assistance for the beneficiary.

  3. If there is no evidence of a Part D plan enrollment but there is clear evidence of both Medicare and Medicaid eligibility (for example, a Medicare card and a Medicaid card or prior history of Medicaid prescription coverage at the pharmacy):

    bill the POS Contractor (WellPoint) for the claim.

    The pharmacist can also call the dedicated pharmacy assistance line to confirm that the beneficiary is in Medicare.

Important Notice

As a result of Governor George Pataki's recent action, pharmacists have been able to temporarily bill Medicaid for pharmacy claims for full benefit duals when using CMS procedures, they have made attempts, and failed, to access Part D plan coverage. Only claims for full benefit dual eligibles with dates of service on January 1, 2006 and after are included under this temporary coverage.

As improvements continue with Part D operations, it is imperative that Medicaid full benefit dual safely transition back to Medicare Part D as their source of pharmacy benefits. As a result, this temporary coverage will end February 15, 2006. Beginning February 16, 2006, the NYS Medicaid program will provide a new interim verification process, which will continue Medicaid payment for full benefit duals between the period February 16 and March 8, 2006. However, pharmacists must complete the CMS procedures above in order to access this interim process. Providers will then be able to verify via this new, interim process, that efforts were made to complete the CMS procedures to bill Part D, and failed. Details regarding the interim verification and claim submission process will be distributed through pharmacy associations. After March 8, 2006, all temporary and interim coverage by Medicaid of Part D covered drugs will end. After this date, only "wrap-around" claims, with an MVS number, will be reimbursed for full benefit duals.

Medicare Part D Benchmark
Prescription Drug Plans (PDP) in NYS

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For people with both Medicare and NYS Medicaid. People in Medicare Advantage Plans should contact their plan directly for benchmark plan information.

CMS recognizes the following plans as benchmark Medicare Prescription Drug Plans available to persons with both Medicare and New York State Medicaid. Dual eligible recipients enrolled in one of these plans pay no premiums.

NOTE: Information contained in this document was updated on 1/20/06.

American Progressive Insurance Co.
Prescription Pathway Bronze Plan Reg 3
Customer service for recipients, pharmacists & prescribers 800-766-3233
Excellus Health Plan, Inc.
Simply Prescriptions
Recipient customer service 800-514-6930    Pharmacists & prescribers 800-724-5033
First Health
First Health Premier
Recipient customer service 888-975-8989   Pharmacists & prescribers 800-421-2342
Group Health Incorporated (GHI)
GHI Medicare Prescription Drug Plan
Recipient customer service 866-557-7300   Pharmacists & prescribers 800-235-4357
Health Net Insurance of NY
Health Net Orange
Recipient customer service 800-806-8811   Prescribers 800-867-6564
Pharmacists help desk 800-693-8951
Humana Insurance Company of NY
Humana PDP Standard
Recipient customer service 800-281-6918   Pharmacists & prescribers 800-448-6262
Pharmacy help desk 800-865-8715 or 800-555-2546
Pacificare Insurance Company
Pacificare Saver & Pacificare Select Plan
Recipients, pharmacists & prescribers can call 800-797-9794
Unicare (Anthem)
Medicare Rx Rewards
Recipient customer service 800-928-6201   Pharmacists & prescribers 800-662-0210
United Healthcare Insurance Co. of NY
United HealthRx
Recipient customer service 866-255-4515   Pharmacists & prescribers 888-492-2949
United Healthcare Insurance Co. of NY
AARP MedicareRx Plan
Recipient customer service 866-255-4515   Pharmacists & prescribers 888-492-2952
United Healthcare Insurance Co. of NY
United Medicare MedAdvance
Recipient customer service 866-255-4515   Pharmacists & prescribers 888-747-5736
Wellcare Health Plans
Wellcare Signature
Customer service for recipients, pharmacists, & prescribers 888-550-5252 or 800-278-5155


All Providers!


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Policy sections of the following manuals are currently available online at

Chiropractor Laboratory
Clinical Psychology Midwife
Durable Medical Equipment Personal Care
Early Periodic Screening Diagnosis
Treatment for Child Health Plus A
Personal Emergency Response System
HCBS/TBI Waiver Physician
Home and Community Based Services Transportation
 Vision Care

When you click the link to your manual, you will find policy information, billing instructions, fee schedules, etc.

Check the eMedNY website frequently for updates to your manual!

Fraud impacts all taxpayers.
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Do you suspect that a recipient or a provider has engaged in fraudulent activities?

Please call:


Your call will remain confidential.

Durable Medical

Separate Provider Identification Number
Each Operating Location
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To receive reimbursement from the New York Medicaid program, Durable Medical Equipment (DME) and Transportation providers must be enrolled in the New York Medicaid program and have a separate provider identification number for each operating location.


An additional operating location can no longer be added to an existing provider service address unless it is a result of an address change.

Identified Problem

Recent audits and provider enrollment activities have identified DME and Transportation companies operating from locations that are not included and/or disclosed to the Department's Medicaid program.

When this situation is identified on audit, it is considered to be an improper practice under Department regulations and could result in administrative action that would affect the provider's participation in the program. This could also result in disallowances or penalties being assessed against the provider.


DME and Transportation providers must individually enroll each location furnishing care, services or supplies for which reimbursement is sought and obtain a separate provider identification number.

Enrollment must be approved by the Department prior to being eligible to receive Medicaid reimbursement.

  • DME and Ambulance providers must obtain Medicare approval prior to submitting their application for enrollment. Medicare approval for DME providers is also site specific.

Information Update

Providers must complete the appropriate forms to inform the Department of additional operating locations or any changes in their status, e.g., ownership, correspondence address, pay-to or service address, etc. This can be done online at:

or call Computer Sciences Corporation at (800) 343-9000, option #5.

The following corrects an error contained in the original January 2006 Medicaid Update article.

In item number 4 below, the third bullet read (in the January edition):

The claim will bypass the PA requirement and pay up to 10% of the amount on file (the repair amount).

This 10% payment is wrong. The new bullet below, within #4, now bolded and italicized, eliminates this wording.

The following is a reprint of the entire article, with the correct wording


Prescribers, Pharmacists
and Nursing Homes


Emergency Procedures for
Durable Medical Equipment Requiring
Prior Approval
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The following procedures will be available to Durable Medical Equipment (DME) providers for dates of service on and after January 23, 2006, for emergency situations in lieu of requesting normal prior approval. Following the procedures described below, you will be able to bypass the prior approval requirement when an emergency situation occurs.


An emergency medical condition (for Medicaid) is defined in 42 CFR 440.255(c) as:

a medical condition...manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.

Only a qualified ordering practitioner may determine, using his or her professional judgment, whether a situation constitutes an emergency. The ordering practitioner's documentation of the specific need for emergency must be maintained in the patient records of the ordering practitioner and DME provider, along with the fiscal order. In such emergency situations, prior approval is not required.

Process to Bypass Prior Approval:

DME providers must indicate the service is of an emergency nature by using the Emergency Indicator on the paper claim form [Box 16a on the paper Claim Form 150001] or electronic claim [Loop 2400, SV109 of the 837P].

There are several different situations which may occur:


  • The service requiring prior approval has a HCPCS procedure code and price identified in the DME Fee Schedule;
  • The service requiring prior approval has a HCPCS procedure code but there is no price identified in the DME Fee Schedule;
  • There is no HCPCS procedure code that identifies the service;
  • The service is a repair of an item with a HCPCS code and price; or
  • The service is a repair of an item without a HCPCS code or price.

1. For DME services that have a HCPCS procedure code and a price on file:

  • Indicate emergency by completing the Emergency Indicator field on either the paper or the electronic claim form.
  • The claim will bypass the PA requirement and pay the amount on file.

2. For DME services that have a HCPCS procedure code but no price identified on the DME Fee Schedule (the Price column reads PA) the claim must be submitted on paper and must include the vendor invoices to support the claim as attachments:

  • Indicate emergency by completing the Emergency Indicator field on the paper claim form.
  • The claim will bypass the PA requirement and pend for Edit 00126 [AMOUNT CHARGED OVER SCREEN PRICE; REQUIRES MANUAL PRICING (DOH)] for manual pricing. The vendor invoice information will be used to price the claim.

3. For equipment with no HCPCS procedure code to identify the service - see 'Exceptions' below.

4. For emergency repairs on equipment with a HCPCS procedure code and price on file:

  • Indicate emergency by completing the Emergency Indicator field on either the paper or the electronic claim form.
  • Use the appropriate HCPCS procedure code with the modifier "-RP".
  • The claim will bypass the PA requirement.


5. For repairs on equipment which have no HCPCS code or no price listed in the DME Fee Schedule:

  • Indicate emergency by completing the Emergency Indicator field on either the paper or the electronic claim form.
  • Use procedure code A9900 on the claim but without modifier "-RP".
    The fee for A9900 has been increased to $250, effective for dates of service on and after January 23, 2006. Claims with the Emergency Indicator will pay up to $250 without prior authorization.
  • If the charge for emergency A9900 repairs is greater than $250, the claim must be submitted on paper with an attached itemized invoice.The claim will bypass the PA requirement and pend for Edit 00126 [AMOUNT CHARGED OVER SCREEN PRICE; REQUIRES MANUAL PRICING (DOH)] for manual pricing based. Providers will be paid actual acquisition cost by manufacturer's invoice plus 50%. Acquisition cost is net any discounts and does not include mailing, shipping, handling, insurance costs or any sales tax.

If a prior approval is subsequently requested for non-emergency repairs on equipment previously repaired on an emergency basis by the same provider, the provider must supply the emergency repair fiscal order and practitioner documentation of need with the current prior approval request.


Air tank

Urgent supply and respiratory items are available through the Dispensing Validation System (DVS) and do not require prior approval.


Rental of acceptable alternatives is available to address the urgent needs of clients awaiting receipt of specific items of DME otherwise requiring prior approval.


This process cannot be utilized for initial purchase of items using the miscellaneous services code, E1399 or K0108, or where an otherwise approved code does not exist. The Department must be assured that any item being claimed using these codes is federally reimbursable.


As with all Medicaid services, the use of the emergency process, in lieu of prior approval, will be periodically reviewed and audited.

Any questions on the above can be addressed to CSC at (800) 343-9000.


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Currently in New York State, at least three children are diagnosed with Type 2 diabetes every week! This alarming growth in the diagnosis of Type 2 diabetes has been associated with the parallel epidemic of childhood obesity and overweight children.


Diabetes is characterized by high blood glucose levels (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both. The two most common types of diabetes are type 1 , accounting for about 5-10% of all diabetes and type 2, accounting for about 90-95% of all diabetes. Type 1 is an autoimmune disease characterized by destruction of the beta cells of the pancreas,, usually leading to absolute insulin deficiency. Type 2 is characterized by insulin resistance and relative insulin deficiency.


Risk Factors for development of Type 2 Diabetes in children include:

  • Overweight/Obesity
  • Family history of Diabetes
  • Race/ethnicity of Hispanic, African American, Native American or Asian American

The NYS Diabetes Prevention and Control Program has awarded eight new projects entitled "Prevention of Type 2 Diabetes in Children"which began October, 2005. The goal of these projects is to modify risk behaviors in infants, toddlers and/or school-aged children (K-12) by increasing opportunities for healthy food choices and/or physical activities in the home, school and community environment.

For more information on the current projects, please call the contractor nearest you.


  • Chenango Health Network-Norwich, NY (607) 337-4171
  • Cornell Cooperative Ext.-Suffolk County (631) 727-7850
  • Erie County DOH (716) 858-7695
  • Glens Falls Hospital-Glens Falls, NY (518) 926-5907
  • Hudson River Health Care-Peekskill, NY (914) 734-8613
  • North General Hospital-New York, NY (212) 423-4070
  • Urban Health Plan-Bronx, NY (718) 991-4833
  • University of Rochester-Rochester, NY (585) 273-2905

For more information on diabetes, you can visit the following websites:

Or you may contact the Diabetes Prevention and Control Program at (518) 474-1222.

The Medicaid program reimburses for medically necessary care, services & supplies for the diagnosis and treatment of diabetes. For more information, please call the Bureau of Program Guidance at (518) 474-9219.


April 19, 2006 Deadline Approaching!
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A new Public Health Law requires that ALL prescriptions written in New York State be issued on an official New York State prescription form.

The new law was enacted to combat prescription fraud and goes into full effect on April 19, 2006.

You are strongly encouraged to begin using official prescription forms for all your written prescriptions now.

After April 19, 2006, pharmacies will fill handwritten prescriptions on official prescription pads only.

You must register with the Department's Official Prescription Program to receive official prescriptions free of charge.

You may receive your registration packet by calling the Official Prescription Program toll-free at

(866) 811-7957.

All Providers

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Computer Sciences Corporation (CSC) announces a schedule of seminars to be offered to providers and their billing staff.

Seminar locations and dates are available at the eMedNY website. Registration is fast and easy.


Go to and register for the eMedNY Training Seminar appropriate for your provider category and location.

If you are unable to access the internet to register, please contact CSC's call center at (800) 343-9000 to obtain a registration form. You may also request seminar schedule and registration information by contacting CSC's Fax on Demand at (800) 370-5809. Order document number 1000 will be faxed to you.

Please refer to these resources frequently for additional seminar offerings.

CSC representatives look forward to meeting with you at upcoming seminars!

All Providers

Stay up to date on the Medicaid Program online at
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This website contains the most current information related to the Medicaid Program. From the website, you can download or print forms and publications necessary to conduct business with the Medicaid Program.

Here are links on the eMedNY homepage and some of the information available to you:

What's New


  • Letters and announcements about recent changes to the Medicaid Program.


  • Provider enrollment and update information forms such as address changes,
  • Link to past and present Medicaid Updates,
  • Frequently asked questions, and
  • Link to on-line license verification website - NYS Education Department Office of the Professions.

Provider Manuals

  • Online Provider Manuals (including policy guidelines, billing instructions, procedure codes and fee schedules, MEVS manuals, prior approval instructions) and much more.


  • Quick reference guides for claims and Threshold Override Applications.



  • Online registration for Medicaid seminars in your area.


  • Contact information for CSC, DOH and other health related information resources.


  • Electronic HIPAA transaction specifications (Companion Documents),
  • Registration information and forms for electronic submissions, and
  • Vendor information.

Questions about the website can be directed to the eMedNY Call Center at (800) 343-9000. Thank you for your continued participation in the New York State Medicaid Program.

All Providers

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As fiscal agent for the Department of Health, Computer Sciences Corporation (CSC) issues 1099 forms to providers at the beginning of each calendar year based on the previous year's Medicaid payments.

1099 Forms for calendar year 2005 will be mailed no later than January 31, 2006.

The 1099 amount is not based on the date of the checks, rather it is based on the date the checks were released to providers.

  • Due to the two-week lag between the date of the check and the date the check is issued, the 1099 amount will not correspond to the sum of all checks issued for your provider ID during the calendar year. The 1099 amount is based on check release date.

Cycles Contained on Calendar Year 2005 Form


The 1099s that will be issued for the year 2005 will include the following:

Check dated 12/20/04 (Cycle 426) released on 01/05/2005


Check dated 12/12/05 (Cycle 1477) released 12/28/05.

Group Practice Providers - Reminder

In order for group practice providers to direct Medicaid payments to a group ID and corresponding 1099 form, providers are reminded that they must submit the group ID number in the appropriate field on the claim (paper or electronic).

Claims that do not have the group ID entered will cause payment to go to the individual provider and his/her 1099.


The above information is provided to assist providers with reconciling the 1099 amount.

Any questions should be directed to CSC's Provider Services at:

(800) 343-9000.


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Missing Issues?
The Medicaid Update, now indexed by subject area, can be accessed online at the New York State Department of Health website: http://www.health_care/medicaid/program/update/main.htm
Hard copies can be obtained upon request by emailing: or by calling (518) 474-9219.

Do You Suspect Fraud?
If you suspect that a recipient or a provider has engaged in fraudulent activities, please call the fraud hotline at: 1-877-87FRAUD. Your call will remain confidential.

As a Pharmacist, Where Can I Access the List of Medicaid Reimbursable Drugs?
The list of Medicaid reimbursable drugs is available at:

Questions About an Article?
For your convenience each article contains a contact number for further information, questions or comments.

Do You Want Information On Patient Educational Tools and Medicaid's Disease Management Initiatives?
Contact Department staff at (518) 474-9219.

Questions About HIPAA?
Please contact CSC Provider Services at (800) 343-9000.

Address Change?
Questions should be directed to CSC at (800) 343-900, option 5.

Patient Eligibility
Call the Touchtone Telephone Verification System (800) 997-1111, (800) 225-3040 or (800) 343-9000.

Fee-for-service Provider Enrollment
A change of address form is available at:

Rate-based/Institutional Provider Enrollment
A change of address form is available at:

Billing Question? Call Computer Sciences Corporation:
Provider Services (800) 343-9000.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at or via telephone at (518) 474-9219 with your concerns.

The Medicaid Update: Your Window Into The Medicaid Program

The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site:http://www.health_care/medicaid/program/update/main.htm