New York State Medicaid Update - May 2012 Volume 28 - Number 6

In this issue…

Policy and Billing Guidance

Primary Care Service Corps (PCSC) -Strengthening the Health Workforce in New York's Medically Underserved Communities

According to federal data, as of May 8, 2012, there were 252 Health Resources and Services Administration (HRSA) designated Health Professional Shortage Areas (HPSAs) across New York State for primary, dental, or mental health; only five counties had no HPSAs. The total shortage of health practitioners in the State is 495 FTEs. Over half of all counties (35 out of 62) have designated HPSAs for all three health disciplines - primary care, dental, and mental health. Demand is rising for primary care practitioners in light of federal health care reform, which may add one million additional people who would newly obtain health care coverage.

To respond to these issues, in March 2012, the New York State Legislature agreed to fund a new program in the 2012-13 NYS budget, the Primary Care Service Corps (PCSC). The 2012-13 NYS budget agreement provides $1 million in funding - $500,000 in state funding matched by an additional $500,000 in federal State Loan Repayment Program funding - for up to 33 loan repayment awards under this program. The program was recommended by the Medicaid Redesign Team's (MRT) Workforce Flexibility and Change of Scope of Practice Workgroup, and subsequently approved as a New York State budget item by the full MRT.

PCSC will increase the supply of non-physician clinicians practicing primary, oral health and mental health care in federally-designated underserved areas by offering financial incentives in the form of loan repayment funding for these clinicians if they agree to fulfill an obligation of a series of years in these underserved areas. By increasing access to primary care, the PCSC would reduce emergency room visits and potentially reduce the attendant costs to the Medicaid program.

Eligible clinicians include:
  • Dentists and dental hygienists;
  • Nurse practitioners;
  • Physician assistants;
  • Midwives;
  • Clinical psychologists;
  • Licensed clinical social workers;
  • Psychiatric nurse practitioners;
  • Licensed marriage family therapists;
  • and Licensed mental health counselors.

Physicians were specifically excluded since they currently are able to access the similar Doctors Across New York (DANY) programs, which were also continued in the 2012-13 NYS budget agreement at about $6 million annually.

It is anticipated that qualifying clinicians would receive up to $60,000 for repayment of qualifying educational loans for the first two years of service ($30,000 for a part-time commitment). For additional years, they would receive up to $32,500 for years three and four; then $25,000 for any additional years for which qualifying educational loan amounts still exist and the obligated service is still eligible for awards. Payments would likely be tiered (i.e., annual amounts adjusted) based on the severity of the health professional shortages in the HPSAs. With the passage of the budget, it is anticipated that contracts for this program could be awarded as early as October 2012.

New York Medicaid Electronic Health Records Incentive Program Update

The NYS Department of Health (NYSDOH) is pleased to announce that as of May 21, 2012, the New York Medicaid Electronic Health Records (EHR) Incentive Program paid over $115 million in federal incentive funds to more than 1,000 New York State hospitals and healthcare practitioners.

The Department continues to review applications for Payment Year 2011 incentive payments that were submitted prior to the April 29, 2012 deadline, and applications for Payment Year 2012 are currently being accepted from providers who are new to the incentive program. Applications for providers' second incentive payment (Meaningful Use Attestation) will be accepted beginning in the fourth quarter of 2012.

If you have not yet registered for the NY Medicaid EHR Incentive Program, we encourage you to visit the website ( or attend one of the informational webinars hosted by the NYSDOH throughout the month of June.

Tuesday, June 5 10:00-11:00AM Eligible Professional Registration & Attestation
Wednesday, June 6 3:00-4:00PM MEIPASS Prerequisites
Thursday, June 7 12:00-1:00PM Meaningful Use, Stage 1 (Eligible Professionals)
Tuesday, June 12 12:00-1:00PM Eligible Hospital Registration & Attestation
Thursday, June 14 12:00-1:00PM Meaningful Use, Stage 1 (Eligible Hospitals)
Tuesday, June 19 10:00-11:00AM Eligible Professional Registration & Attestation
Thursday, June 21 10:00-11:00AM Eligible Hospital Calculation Workshop
Tuesday, June 26 12:00-1:00PM MEIPASS Prerequisites
Wednesday, June 27 10:00-11:00AM Meaningful Use, Stage 1 (Eligible Professionals)

The webinar schedule is subject to change based on interest levels. For the complete schedule or to register for one of the webinars, please view the webinar schedules posted on the website at:

Current Month:

Next Month:

Long Term Home Health Care Program (LTHHCP) 2012 Participant Expenditure Caps

The Long Term Home Health Care Program (LTHHCP) waiver is a coordinated plan of care and services for individuals who would otherwise be medically eligible for placement in a hospital or residential health care facility for an extended time. LTHHCP services can be provided when the total monthly Medicaid expenditures for health and medical services for an individual do not exceed seventy-five percent of the cost of care in either a skilled nursing facility (SNF) or a health-related facility (HRF) located within an individual's local district of fiscal responsibility. To be eligible for the LTHHCP waiver, Medicaid participants must be able to be served safely and effectively with a Plan of Care; the cost of which falls within the seventy-five percent budget cap.

LTHHCP expenditure caps are calculated in accordance with 10 NYCRR Part 86-5.10. Expenditure caps are based on the January 1, 1992, average Medicaid reimbursement rates for nursing facilities in a county trended forward to the current year. Due to a zero trend factor in 2012, the participant expenditure caps have not changed from the maximum allowed in 2011.

If you have questions regarding the LTHHCP, please contact Vicki Rockefeller at (518) 474-5271.

Mandatory Medicaid Managed Care Expanding to Tioga County

Effective June 2012, managed care enrollment will be required for most Medicaid beneficiaries residing in Tioga County. Once a mandatory managed care program is implemented in a county, it is expected that the enrollment of all eligible Medicaid beneficiaries will take up to twelve months to complete.

Providers should check the Medicaid Eligibility Verification System (MEVS) prior to rendering services to determine Medicaid eligibility and the conditions of Medicaid coverage. Providers are strongly encouraged to check eligibility at each visit as eligibility and enrollment status may change at any time. If the Medicaid beneficiary is enrolled in a Medicaid managed care plan, the first coverage message will indicate "Eligible PCP".

MEVS responses no longer include scope of benefits information so providers will need to contact the health plan to determine services covered by them. Service Type codes will be used to identify carved-out services where possible. Medicaid will not reimburse a provider on a fee-for-service basis if a medical service is covered by the plan.

For more information on MEVS messages, please see the February 2011 Special Edition Medicaid Update article at:

Providers may call the eMedNY Call Center at (800) 343-9000 with any Medicaid billing issues. Medicaid beneficiaries may call NY Medicaid Choice at (800) 505-5678 or contact their local department of social services (LDSS) to learn more about managed care. For additional information on managed care covered services and managed care plan types, please see the December 2010 Medicaid Update article entitled "Managed Care Covered Services" available online at:

Medicare Providers May Not Bill QMBs for Medicare Cost-Sharing

This article provides guidance to Medicare providers to help them avoid inappropriately billing Qualified Medicare Beneficiaries (QMBs) for Medicare cost-sharing, including deductible, coinsurance, and copayments. This is known as "balance billing."

Balance Billing of QMBs Is Prohibited by Federal Law

Under current law, Medicare providers cannot balance bill a QMB. Section 1902(n)(3)(B) of the Social Security Acts prohibits Medicare providers from balance billing QMBs for Medicare cost-sharing.

PLEASE NOTE: This section of the Act is available online at: Home/ssact/title19/1900.htm.

Specifically, the statute provides that the Medicare payment and any Medicaid payment are considered payment in full to the provider for services rendered to a QMB. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who balance bill QMB patients may be subject to sanctions based on Medicare provider requirements established in Sections 1902(n)(3)(C) and 1905(p)(3) of the Social Security Act. Medicare providers who violate these billing restrictions are violating their Medicare provider agreement.

QMBs and Benefits

QMBs are persons who are entitled to Medicare Part A and are eligible for Medicare Part B; have incomes below 100 percent of the Federal Poverty Level; and have been determined to be eligible for QMB status by their State Medicaid Agency.

  • Medicaid pays the Medicare Part A and B premiums, deductibles, co-insurance and co-payments for QMBs.
  • New York State Medicaid will pay the Part C Medicare Advantage premiums when it is determined cost effective to do so. These premiums may also be used to meet a Medicaid spend down or be used as an income deduction.
  • Regardless of whether Medicaid opts to pay the Part C premium, the QMB is not liable for any co-insurance or deductibles for Part C benefits.

Medicare Crossover Billing

Providers must bill claims for Medicare/Medicaid beneficiaries to Medicare. Medicare will then reimburse its portion to the provider and the provider's Medicare remittance will indicate that the claim will be crossed over to Medicaid. Medicare will send the claim data to GHI and they will submit the data to New York State Medicaid for processing and payment of the deductible, coinsurance or co-pay amounts (also known as the Medicare Patient Responsibility). Medicaid will deny the claim if a claim is crossed over with no Patient Responsibility. Providers may call the eMedNY Call Center at (800) 343-9000 with any QMB billing issues. Questions regarding the QMB balance billing policy may be referred to the Third Party Liability Unit at (518) 473-5330.

Transportation Fees Change For Livery and Stretcher Van Services in New York City

Effective for dates of service on or after May 1, 2012, the following one way reimbursement fees are established for the transportation of NYC fee-for-service Medicaid enrollees traveling to and from necessary medical care via livery or stretcher van.

Livery One Way Fee Procedure Code Modifier
Inside the Common Medical Marketing Area 1 $20.00 A0100
Outside the Common Medical Marketing Area 2 $25.00 A0100 TN
Stretcher Van 3 One Way Fee Procedure Code Modifier
7 AM to 7 PM Monday through Friday, except Certain Holidays 4 $76.00T2005
Weeknights 7 PM to 7 AM, Weekends, and Holidays $98.00T2005 TU

1 Inside the Common Medical Marketing Area Livery

Trips Originates in Trip ends In
1 Brooklyn Brooklyn
2 Brooklyn Queens
3 Bronx Bronx
4 Bronx Upper Manhattan Above 110th Street
5 Bronx Westchester County
6 Upper Manhattan Above 110th Street Bronx
7 Upper Manhattan Above 110th Street Upper Manhattan Above 110th Street
8 Upper Manhattan Above 110th Street Westchester County
9 Lower Manhattan Below 110th Street Lower Manhattan Below 110th Street
10 Queens Brooklyn
11 Queens Queens
12 Queens Nassau County
13 Staten Island Staten Island

2 Outside the Common Medical Marketing Area Livery

Trips Originates in Trip ends In
1 Brooklyn Bronx
2 Brooklyn Staten Island
3 Brooklyn Brooklyn Upper/Lower Manhattan
4 Bronx Brooklyn
5 Bronx Lower Manhattan Below110th Street
6 Bronx Queens
7 Bronx Staten Island
8 Queens Bronx
9 Queens Staten Island
10 Queens Upper/Lower Manhattan
11 Staten Island Brooklyn
12 Staten Island Bronx
13 Staten Island Queens
14 Staten Island Upper/Lower Manhattan
15 Upper/Lower Manhattan Brooklyn
16 Upper/Lower Manhattan Queens
17 Upper/Lower Manhattan Staten Island
18 Lower Manhattan Below110th Street Bronx
19 Lower Manhattan Below110th Street Upper Manhattan Above 110th Street
20 Upper Manhattan Above 110th Street Lower Manhattan Below110th Street

3 Stretcher Van: Used when the enrollee cannot walk, is confined to bed, cannot sit up or sit in a wheelchair, and does not require medical attention during transport.

4 Holidays: New Year's Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving, and Christmas

Questions regarding this fee schedule may be sent via e-mail to:, or contact the Transportation Unit at (518) 473-2160.

New York State Partnership for Long Term Care Insurance Update

This year brings some of the most sweeping improvements to the Partnership for Long Term Care Program (PLTC). These changes are designed to modernize the program.

The four major changes to the program are as follows:

A new plan option will be available offering a Total Asset Protection Plan with two years of nursing home coverage; or four years of home care or residential care (at half the nursing home rate). A Medicaid State Plan Amendment to include this option has already been approved by the Centers for Medicare & Medicaid Services (CMS). This offering (2-4-50) will be available upon final publication of a new Regulation #144 by the Department of Financial Services. These regulations will be final on June 1, 2012.

The second change is the decision by NYS to participate in Reciprocity as offered in the Federal Deficit Reduction Act of 2005. This change will allow New Yorkers who relocate to one of the forty other participating states to take advantage of both asset protection and Medicaid Extended Coverage in those states at a dollar-for-dollar level based on the amount of LTC insurance paid on their behalf. This provision will also allow PLTC participants from the other forty states who relocate to New York to achieve the same benefit. A Medicaid State Plan Amendment to include this option has already been approved by CMS. Reciprocity will be available upon final publication of a new Regulation #144 by the Department of Financial Services. As noted above, a final rule will be in place on June 1, 2012. A new disclosure statement explaining Reciprocity in detail will be attached to any new PLTC policy.

The third change relates to required inflation protections. Every PLTC policy sold must cover a minimum daily benefit amount, and this amount is increased annually by an inflation factor. Historically, this factor has been 5 percent, but research shows that a more accurate amount would be 3.5 percent. This new level will now be available, subject to the choice of the policyholder, upon final publication of a new Regulation #144 by the Department of Financial Services. As noted above, a final rule will be in place on June 1, 2012.

The final change relates to the way insurance agents are trained and certified to sell PLTC policies. In the past, NYSDOH staff has traveled around the state and agents have spent valuable time sitting in classrooms to receive this training. DOH has opened an all on-line training and certification program.

These changes are designed to make the PLTC policies more attractive as a benefit to policyholders and a savings to the Medicaid program. This program is one of the "win-win" activities that result when public-private partnerships are carefully planned and implemented for the benefit of all.

For more information regarding the Partnership for Long Term Care program, please visit:

Questions? Please contact the New York State Partnership for Long Term Care at 1-866-950-PLAN or via e-mail to:

Ordering Non-Emergency Transportation in New York City New Form Used to Justify the Mode of Transport

Medicaid will cover the costs of transportation provided to an eligible beneficiary, when payment for transportation expenses is essential for an eligible enrollee to obtain necessary medical care and services which may be paid for under the Medicaid program.

In New York City, a new form has been developed to assist practitioners and/or facilities order the appropriate mode of transport. The form is available for download at:

Questions regarding this article may be e-mailed to:, or contact the Transportation Unit at (518) 473-2160.

Brooklyn and Queens Medical Practitioners and Facilities:

Numbers to Call When Ordering Transportation

The NYS Department of Health (NYSDOH) and its contractor, LogistiCare Solutions, has implemented non-emergency medical transportation (NEMT) management services for New York City Medicaid fee-for-service enrollees (i.e., those not in a managed care plan) who are receiving Medicaid covered services in Brooklyn. Starting for dates of service July 1, 2012, Queens based practitioners and facilities will submit requests directly to LogistiCare (those not in a managed care plan). All trips must be pre-arranged and confirmed by LogistiCare. Below is information to help you in the transition.

Key Terms and Telephone Numbers

  • A standing order is a regularly reoccurring (three or more times per week, for 3 or more months' duration) reservation for transport to a Medicaid covered service. For example, Monday, Wednesday and Friday transport to and from dialysis.
  • A demand response trip is a less frequent, episodic trip. For example, a trip to and from the doctor next Wednesday.
Facility Services Department 877‑585‑8758 Monday - Friday
7a.m. - 6p.m.
This is the number the medical provider (you) can call to speak to one of our specialists to request standing order or demand response transport for an enrollee.
Facility Services Dept. fax 877‑585‑8758 24/7 Case managers or social workers fax the 2015 Medical Justification Form or the Standing Order Request forms to this number.
"Where's My Ride" 877‑564‑5923 24/7 Call this number if there is a service issue or complaint, or when the enrollee needs to be picked up.
Reservation Number for Enrollees 877‑564‑5922 Monday - Friday
7a.m. - 6p.m.
This is the number a Medicaid fee-for-service enrollee can call to request transportation. Urgent & hospital discharges trips can be called in 24/7. is the website with documents, webinar and more information regarding arranging non-emergency transportation services for fee-for-service Medicaid enrollees. Requests for routine NEMT services must be pre-arranged with LogistiCare 72 hours or 3 days in advance, as illustrated in the chart below. Requests for urgent, same day or next day NEMT are reserved pending confirmation from the medical provider that the enrollee needs to come in today or tomorrow, and that treatment cannot be delayed to another day.

Three (3) day's prior for routine non-emergency transportation:

Appointment is on: Contact LogistiCare the:
Saturday Wednesday before
Sunday Thursday before
Monday Friday before
Tuesday Friday before
Wednesday Friday before
Thursday Monday before
Friday Tuesday before

Pharmacy Update

Hepatitis C Agents (Injectable Agents and Protease Inhibitors) Subject to Prior Authorization

As a result of Drug Utilization Review (DUR) Board recommendations, effective June 21, 2012, certain Hepatitis C agents (Injectable Agents and Protease Inhibitors) will be subject to prior authorization.

Prior authorization requirements are intended to ensure that utilization of Hepatitis C agents is appropriate and follows the most recent practice guidelines by the American Association for the Study of Liver Diseases (AASLD).

Prior authorizations for Hepatitis C Protease Inhibitors and Injectable Agents may be requested by completing the form found at: The completed form must then be faxed to the clinical call center at (800) 268-2990.

Key Points:

  • The form must be completed if an injectable Hepatitis C Virus (HCV) agent and/or HCV Protease Inhibitor is being requested for a patient.
  • Boceprevir (Victrelis®) and telaprevir (Incivek®) are new products that belong to the HCV Protease Inhibitor class and must be used concurrently with both peginterferon and ribavirin.
  • HCV Protease Inhibitors are only approved for the treatment of HCV genotype 1 infection in adults. Patients' baseline HCV genotype must be established prior to use.
  • Victrelis® treatment should only be initiated after a 4-week lead-in period of peginterferon and ribavirin.
  • HCV-RNA viral load must be tested at baseline and also at critical points during treatment (treatment weeks 4, 8, 12 and 24). Laboratory test results and answers to additional questions must be documented on the fax form and resubmitted at each critical point.
  • Duration of treatment is determined by the patient's response and previous treatment status.
  • Patients who have previously failed on Incivek® or Victrelis®, should not be treated with the other HCV Protease Inhibitor due to the risk of cross resistance.

For additional clinical information on Hepatitis C, including an overview of the HCV Protease Inhibitors and interactive treatment algorithms, please visit:

The most up-to-date Preferred Drug List (PDL), with a full listing of preferred and non-preferred drugs for each of the drug classes currently subject to the PDP is available online at: