New York State Medicaid Update - July 2014 Volume 30 - Number 7

In this issue...July 2014

Policy and Billing Guidance

EPIC Income Levels Expanded to Provide Drug Coverage for More New York State Seniors

GOOD NEWS! Effective April 1, 2014, The NYS 2014-15 budget included the expansion of the Elderly Pharmaceutical Insurance Coverage Program (EPIC) to cover the prescription needs of more seniors. Eligible income brackets were expanded from $35,000 to $75,000 for singles and from $50,000 to $100,000 for married couples.

The new income brackets will be added to existing ones and current EPIC members will not be impacted. EPIC income is based on the previous income year and does continue to include the reporting of net Social Security Income. Seniors must also be a NYS resident, 65 or older and be enrolled or eligible to enroll in a Medicare Part D drug plan and not be receiving full Medicaid benefits.

EPIC provides secondary prescription coverage for Medicare Part D and EPIC covered drugs after any Medicare Part D deductible is met. By using EPIC together with Medicare Part D, members save more money on the cost of their prescription drugs.

For many seniors, it is less expensive to enroll in EPIC and Medicare Part D than just Medicare Part D alone. EPIC pays the Part D drug plan premiums up to $37.23 per month in 2014 for members with income up to $23,000 single or $29,000 married. Higher income members are responsible for paying their Medicare Part D premiums but will receive Part D assistance in the form of reduced EPIC deductibles.

Seniors may apply for EPIC at any time during the year even if they do not already have a Medicare Part D Plan. Enrolling in EPIC will provide eligible seniors a Special Enrollment Period from Medicare allowing them to join a Medicare Part D drug plan or switch to another Medicare Part D plan outside of their Open Enrollment Period.

Join EPIC today for additional savings on your Medicare Part D prescription drugs.

For an application or more information, please call the toll-free EPIC Helpline at (800) 332-3742 Monday through Friday from 8:30 AM to 5:00 PM or visit the EPIC website at and click on EPIC for Seniors on the left side of the page.

Update on the Fully Integrated Duals Advantage (FIDA) Demonstration

The New York State Department of Health (NYSDOH) Division of Long Term Care, in partnership with the Centers for Medicaid and Medicare Services (CMS), is implementing the Fully Integrated Duals Advantage (FIDA) demonstration project. NYSDOH is entering into a three-way contract agreement with CMS and health plans to implement this three-year demonstration program. Through this demonstration, certain dual eligible individuals will be enrolled into fully-integrated managed care products. FIDA eligible individuals enrolled in a Managed Long Term Care (MLTC) plan will "convert" to their Plan's FIDA product.

FIDA will be become effective January 2015 for dual eligibles residing in Region I, which consists of the following counties: Bronx, Brooklyn, Kings, Queens, Richmond, and Nassau. Opt-in enrollment will begin in January 2015 and passive enrollment will begin April 2015. In Region II, which consists of Suffolk and Westchester counties, opt-in enrollment will begin on April 1, 2015, and passive enrollment on July 1, 2015. In FIDA, participants can get all of their Medicaid and Medicare benefits through one managed care plan.

Highlights of the FIDA Demonstration include:

  • FIDA participants will not have to pay plan premiums, co-pays, or deductibles.
  • FIDA will provide patient centered service planning through an interdisciplinary team (IDT) approach. The IDT will be a care team in which the FIDA member can choose family members, doctors, nurses or personal attendants to join his or her IDT to help make care decisions and access to services.
  • FIDA offers an expanded package of covered items and services which includes traditional Medicaid and Medicare benefits as well as behavioral health, home and community based waiver services and community and facility long term care services. Providing fully integrated care will improve health outcomes for dual eligible individuals.
  • In addition to having an integrated package of covered items and services, FIDA will offer an integrated appeals process whereby the most consumer-favorable elements of the Medicare and Medicaid grievance and appeals systems are incorporated into a consolidated, integrated grievance and appeals system for FIDA Participants.
  • Participants will also have access to the services provided by the State Ombudsman which will provide direct assistance to individuals and their families in navigating their coverage, and in understanding and exercising their rights and responsibilities.

For more details about the FIDA program please see:

Attention Family Planning Providers:

Clarification of Medicaid Family Planning Services for Beneficiaries Enrolled in the Family Planning Benefit Program (FPBP) and the Family Planning Extension Program (FPEP)

During February 2008, the New York State Department of Health (NYSDOH) announced changes to Medicaid coverage for additional procedures and services performed during a family planning visit as well as follow-up procedures and treatment for "limited medical conditions" diagnosed during a family planning visit for FPBP and FPEP enrollees. Additionally, New York State authorized coverage of the follow-up treatment of specific sexually transmitted infections (STIs) when provided during a family planning visit. The Centers for Medicare and Medicaid Services (CMS) recently issued State Medicaid Director Letter #14-003, dated April 16, 2014, clarifying the coverage of family planning-related services, specifically the diagnosis and treatment of STIs.

The United States Preventive Services Task Force recommends "high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs" (where increased risk includes patients with an active STI).¹ In addressing the needs of a patient with an active sexually transmitted infection (STI), providers will, as a matter of course, provide behavioral counseling on contraceptives. Contraceptive counseling is always a covered family planning service.

Prior to this clarification, under FPBP and FPEP, Medicaid reimbursement was only available when the diagnosis and treatment of an STI were provided as part of, or as a follow up to, a family planning visit (primary purpose of the medical visit was contraceptive management and the diagnosis and treatment of an STI, or other related condition was secondary). STI counseling and treatment was always covered for enrollees with full Medicaid coverage. This clarification applies to services provided to both men and women with FPBP and FPEP coverage on and after April 16, 2014.

To meet program requirements and receive Medicaid reimbursement, all claims processed for FPBP and FPEP recipients must contain a family planning, or family planning related) procedure code from the list provided below. In addition one of the diagnosis codes must be in the V25 contraceptive management series. Please see billing instructions

Required Medicaid Claim Information

Family Planning Visit (Family Planning Service(s) with or without Treatment for Limited Medical Conditions and/or STIs)

To bill for these services, claims must contain:

  • A "Y" in the Family Planning Box.
  • A primary ICD-9CM diagnosis code in the V25 series.
  • The appropriate CPT evaluation and management visit code, initial visit (Table D), or follow-up visit (Table E).
  • The appropriate CPT code for the procedure(s) or medical supply (Table A) or (Table B).
  • Clinic claims must also include the clinic rate code.

Follow-up Visit for Treatment for Limited Medical Conditions Diagnosed During a Previous Family Planning Visit

To bill for these services, claims must contain:

  • A primary or secondary ICD-9CM diagnosis code in the V25 series.
  • A "Y" in the Family Planning Box when primary diagnosis is in the V25 series.
  • The appropriate CPT-4 procedure code(s) performed from the approved follow-up procedures (Table B)
  • The appropriate CPT-4 evaluation and management follow-up visit code (Table E).
  • Clinic claims must also include a clinic rate code.

Visit for Diagnosis and Treatment of Sexually Transmitted Infections "pursuant to" family planning Services

To bill for these services, claims must contain:

  • If the primary reason for the follow-up visit is for treatment of a STI, the primary ICD-9 CM diagnosis code must be the STI (Table C) and the secondary diagnosis code must be in the V25 series.
  • If the primary reason for the follow-up visit is for family planning and STI treatment is secondary, the primary ICD-9CM diagnosis code must be in the V25 series and the secondary diagnosis code must be the specific STI (Table C).
  • A "Y" in the Family Planning Box when primary diagnosis is in the V25 series.
  • A CPT-4 procedure code for an evaluation and management visit (Tables D and E).
  • The appropriate CPT code for the procedure(s) or medical supply (Table A) or (Table B).
  • Clinic claims must also include a clinic rate code.

FPBP Transportation Benefits

Transportation is a Medicaid covered service available through the FPBP. Medicaid will reimburse the most appropriate mode of transportation required to transport an eligible enrollee to a FPBP covered service. Providers should consult the Transportation manual to obtain information regarding transportation policy guidelines, procedures and the county contact list. The manual can be viewed at:

Questions? Please call the Bureau of Policy Development and Coverage at (518) 473-2160.

Table A: Approved Family Planning Procedure Codes (items and procedures must clearly be provided or performed for family planning purposes)
00851 11982 58565 71010 77081 93307 A4268 J7301 J7307
00921 55250 58600 71015 89321 96372 A4931 J7302 S4993*
00952 55450 58615 71020 93000 A4264 J1050 J7303
11976 58300 58670 77078 93010 A4266 J1056 J7304
11981 58301 58671 77080 93040 A4267 J7300 J7306

*Please see the February Medicaid Update article Reimbursement Available to Family Planning Clinics Dispensing Oral Contraceptives to Medicaid recipients at:

Table B: Procedure Codes for Treatment of Limited Medical Conditions (conditions diagnosed during a family planning visit)

10060 56501 74000 82247 84144 85378 86780 87207 87590 88154
10140 56700 76830 82270 84146 85576 86781 87210 87591 88155
11420 56820 76856 82465 84443 85610 86900 87252 87620 88160
11421 56821 76857 82550 84703 85651 86901 87254 87621 88161
17110 57061 80048 82553 85002 85652 87015 87255 87797 88162
17111 57420 80053 82565 85004 85730 87040 87270 87798 88164
46900 57421 80061 82570 85007 86580 87070 87273 87800 88165
46922 57452 80076 82575 85013 86592 87075 87274 87801 88173
46924 57454 81000 82670 85014 86593 87077 87320 87808 88174
54050 57455 81001 82677 85018 86631 87081 87340 87899 88175
54055 57456 81002 82947 85025 86632 87086 87390 88141 88302
54056 57460 81003 82948 85027 86687 87088 87486 88142 88305
54057 57461 81007 82950 85032 86689 87102 87490 88143 88307
54060 57505 81015 82951 85045 86696 87110 87491 88147 99070
54065 57510 81025 83001 85048 86701 87164 87495 88148 J0696
56405 57511 82040 83002 85049 86702 87166 87510 88150
56420 58100 82043 83690 85210 86703 87205 87535 88152
56440 58340 82150 84075 85300 86762 87206 87536 88153
Table C: ICD-9 CM Diagnosis Codes for Sexually Transmitted Infections
054.10-054.12 054.40-054.1 054.71-054.74 054.8-054.9 078.19 079.4
054.13 054.43-054.44 054.79 077.0 078.88 131.0-131.9
054.19 054.49 090-099.9 077.98 079.88
054.2-054.3 054.6 078.1 078.11 079.98
Table D: Procedure Codes for Evaluation and Management Services (new patient)
99050 99201 99203 99205 99242 99244 99384 99386
99051 99202 99204 99241 99243 99245 99385
Table E: Procedure Codes for Evaluation and Management Services (established patient)
99050 99211 99213 99215 99242 99244 99394 99396
99051 99212 99214 99241 99243 99245 99395

Smoking Cessation Counseling Includes Smokeless Tobacco Products

This notice is to clarify that Medicaid coverage of smoking cessation counseling (SCC) for all Medicaid beneficiaries includes cessation services for smokeless tobacco use. Smokeless tobacco products include: dip, chew, snuff, snus (a moist powder tobacco product) and dissolvable tobacco products such as pellets, strips and toothpick-like sticks.

Smokeless tobacco products contain nicotine and are just as addictive as cigarettes. They can cause cancers of the mouth, tongue, cheek, gum, pharynx, larynx, esophagus, stomach and pancreas and precancerous mouth lesions, receding gums, gingivitis, abrasion of teeth, cavities, bone loss around the roots of teeth and tooth loss. In addition, use of smokeless tobacco increases the risk of cardiovascular disease, including heart attacks.

Despite the risks and harms, a growing number of teens are using smokeless tobacco as an alternative to or concurrently with combustible tobacco. In 2013, 7% of New York State high school students used smokeless tobacco, up 60% from a decade earlier, while the percentage of youth who smoked cigarettes dropped almost in half from 20.2% to 10.6%.

Among New York State adults (ages 18 and older), 2.3% used smokeless tobacco in 2012, up from 1.4% the year before, while the cigarette smoking rate was 16.2%, the fifth lowest adult smoking rate in the nation.

For more information about smokeless tobacco products, please refer to the July 2001 Medicaid Update or see the National Cancer Institute's fact sheet on Smokeless Tobacco and Cancer.

For a comprehensive summary of Medicaid SCC policy and billing guidelines, please refer to the April 2011, December 2013 and May 2014 Medicaid Updates.

Questions regarding Medicaid Managed Care or Family Health Plus should be directed to the enrollee's Medicaid Managed Care or Family Health Plus plan. Questions regarding FFS coverage or SCC billing may be directed to the eMedNY Call Center at (800) 343-9000 and policy questions to the Division of Program Development and Management at (518) 473-2160.

Attention Operators of OPWDD Services, Facilities or Programs

Supervised Individualized Residential Alternatives (IRAs) and Supervised Community Residences (CRs)

Effective July 1, 2014, Supervised IRAs and CRs, certified by OPWDD under the Home and Community Based Services (HCBS) waiver, will transition from a monthly to a daily unit for the purposes of service recording and billing. Supportive model IRAs and CRs will continue to use the existing monthly service unit. A Supervised IRA/CR has staff onsite or proximately available 24 hours a day. A Supportive IRA/CR provides variable amounts of oversight depending on the individual's need for supervision. The chart below identifies three new rate codes established to accommodate the new daily service unit for supervised model facilities operated by voluntary agencies:

Rate Code Defined Use
4437 Service Day: Submitted when qualifying residential habilitation services were delivered and were appropriately documented.
4438 Retainer Day: Submitted when a resident was absent from the facility due to a temporary stay (i.e., expected to return to the IRA or CR) in a hospital, skilled nursing facility, or any other institutional, inpatient, or residential facility reimbursed by Medicaid.¹
4439 Therapy Leave Day: Submitted when an individual is temporarily absent (i.e., expected to return) from the facility for the purpose of visiting with family or friends and receives no residential habilitation services from agency staff that day.

A similar series of three rate codes (4428-4430) exists for state operated supervised IRAs. For any single date of service, one and only one supervised IRA/CR rate code may be billed for a resident. When a particular day could potentially be recorded under multiple rate codes, the conflict may be resolved by observing resident's status at 11:59pm. For example, if a residential habilitation service is rendered to a resident in the morning, but the same resident is later admitted to the hospital for an overnight stay, the correct rate code to bill is 4438. Likewise, in the case of an individual transferring to an IRA operated by another agency, it is the receiving agency that will bill the service day. Effective July 1, 2014, providers must also select the proper location code based on the resident's eligibility for "enhanced" (also known as "template") funding. The following chart identifies the four location codes established to support supervised IRA/CR billing as of 7/1/14:

Location Code Defined Use
005 Regular funding. This includes the vast majority of supervised IRA/CR residents.
006 Approved for enhanced funding - Specialized Level
007 Approved for enhanced funding - Highly Complex Level
008 Approved for enhanced funding - Auspice Change or SNF Transfer.

OPWDD provides specific written authorization when an individual is approved for enhanced funding. When such written authorization does not exist, location 005 must be used. Questions regarding a particular resident's eligibility for enhanced funding should be directed to the appropriate OPWDD Regional Office.

Administrative Memorandum (ADM) # 2014-01 outlines the service documentation requirements associated with the new daily service unit. The ADM is available at the following link:

Questions regarding service documentation requirements can be directed to OPWDD's Waiver Management Bureau at (518) 486-6466. Questions regarding the billing changes can be directed to OPWDD's Central Operations Bureau at (518) 402-4333.


¹ For the first year of per diem billing for supervised IRA services, July 1, 2014 to June 30, 2015, retainer day services will be paid at $0. Providers are expected to record and submit claims for these days even though paid at $0. Commencing July 1, 2015, the first 14 retainer days (4438) billed for an individual during an annual July to June period will pay at the provider's payment rate for rate code 4438. The 15th day, and all retainer days thereafter, will pay at $0. Although retainer days after the initial 14 for an individual will pay at $0, it is still important for providers to record and submit claims for these days. Failure to do so will result in an assumed absence or vacancy. This could negatively impact future rate calculations. Note, during the July 1, 2014-July 30, 2015 period, retainer day reimbursement will be provided by revision of the Service Day and Therapy Leave Day rate when reconciliation occurs at the mid-point and end of this period.

Requests for Livery Transportation of New York City Enrollees

Enrollees travelling to medical care and services are expected to use public transit if they already use public transit for normal activities of daily living. Further, enrollees who use public transit for normal activities of daily living and live no more than 1/2 mile from their medical destination are not eligible to receive reimbursement of any subway or bus travel with Medicaid funded MetroCards. Medicaid funded MetroCard reimbursement is reserved only for those enrollees who use public transit traveling to a medical destination and reside more than 1/2 mile from the medical destination.

There are enrollees who require a livery service to access medical services due to some disabling condition. For these enrollees, medical practitioners will be asked by the Department's transportation manager, LogistiCare, to submit a new and updated Medicaid Transportation Justification Request (Form 2015) with compelling medical justification for livery transportation. Submission of this form will be necessary to ensure uninterrupted livery travel to future medical care and services.

Currently, there are some enrollees who now use a livery service to their medical care, but can use public transportation. These enrollees who have no disabling condition limiting their ability to use public transit will be moved to public transit by September 30, 2014.

If you have any questions regarding this policy, please contact LogistiCare at (866) 564-5911.

Medicaid Electronic Health Records (EHR) Incentive Program Update

The New York Medicaid EHR Incentive Program provides financial incentives to eligible practitioners and hospitals to promote the transition to EHRs. Providers who practice using EHRs are in the forefront of improving quality, reducing costs, and addressing health disparities. Since December 2011 over $590.4 million in incentive funds have been distributed within 14,306 payments to New York State Medicaid providers.

NY Medicaid EHR Incentive Program (PDF, 1pg.)


Requirements for Telephoned Prescription Drug Orders

Prescribers may telephone prescriptions and fiscal orders for drugs directly to a pharmacy unless otherwise prohibited by State or federal law or regulations. The pharmacist is responsible to make a good faith effort to verify the prescriber's identity and validity of the prescription if the prescriber is unknown to the pharmacist.

  • A telephone order must be reduced to writing in conformance with the format described in 18 NYCRR 505.3(b)(5) and NYS Education Law [subdivision (4) of Section 6810 either through written documentation or electronic record, indicating the time of the call, the name of the prescriber, and initials of the pharmacist (See the NYS Medicaid Program Pharmacy Manual Policy Guidelines version 2013-1 and all editions between 2006 -1 and 2010-2 as well as the Medicaid Updates: April 2005, Vol. 20, No.5 and May 2007, Vol. 23, No.5)
  • The date of the call of the telephone order must also be memorialized as noted in the Rules of the Board of Regents 8 NYCRR 29.7(a)(1) and 8 NYCRR 29.7 (a)(2).
  • If a prescriber's employee provides the telephone order the retained written documentation of the call should identify the name of the prescriber's employee who provided the telephone order.
  • Prescriptions for multi-source brand drugs requiring "dispense as written" and "brand necessary" may be ordered over the telephone.
  • When an ordering prescriber conveys a prescription over the telephone, it is the responsibility of the ordering prescriber to notate in the Medicaid beneficiary's medical record in their own handwriting that the drug is "brand medically necessary," and the reason that a brand name multi-source drug is required.
  • A follow-up hardcopy of a controlled prescription drug telephone order is required by State and Federal law. (See Public Health Law Art. 33 § 3334; § 3337)
  • A follow-up hardcopy of a non-controlled prescription drug telephone order is not required.
  • Pharmacists must assure the accuracy of information contained on Medicaid pharmacy claims, particularly prescriber information.
  • When billing for these claims, the pharmacist must submit all 9's in place of the official prescription serial number to identify oral prescriptions.

Automatic refills are not allowed. Relevant guidance can be found at

Questions? Please contact the Medicaid Policy Unit at (518) 486-3209 or via e-mail to:


eMedNY ICD-10 Testing Opens

On July 28, 2014 eMedNY opened the Provider Testing Environment (PTE) for submitters to begin testing Medicaid claims with ICD-10 diagnosis codes. In addition inpatient hospital claims that utilize ICD-10 procedure codes may be tested beginning on this date.

Date of Service Requirement: When submitting test claims with ICD-10 codes submitters must use a date of service of July 1, 2014 or any date of service up to the date of the test submission. Future dates are not allowed. Submitters who may be testing claims with ICD-9 codes must use a date of service prior to July 1, 2014.

What is PTE?: The eMedNY Provider Testing Environment is designed to enable NYS Medicaid trading partners to test batch and real-time Electronic Data Interchange (EDI) transactions using the same validation, adjudication logic, and methods as the eMedNY production environment. Test transactions submitted to the eMedNY PTE undergo processes that verify and report on data structure and content to the same degree of stringency as live transactions sent to the eMedNY production environment, and receive, in most cases, the same system responses at each step. For similar inquiries, the response in the PTE may not be identical to the response in the production environment. For example, edits involving duplicate and near-duplicate claims, or prior authorization submissions, are not applied in PTE, so as to allow for iterative testing. Also no claim, or authorization, requests are pended in PTE.

PTE Access Methods: eMedNY PTE can be accessed using any of your existing eMedNY Access Methods with a few exceptions (see below).

Test Indicator

Since existing access methods are being used for PTE access, it is critical the test indicator is valued in the inbound/outbound transactions.


For ASC X12 transactions: "Test Indicator" in ISA15 is set to "T"

For NCPDP Batch 1.2/D.0 transactions: File Type (702-MC) field in the NCPDP Batch Header is set to "T"

No "Test" indicator has been defined for NCPDP Real-time transactions, therefore, a separate phone number has been established. Connect using (800) 433-1747.

Important Note: If the appropriate indicator for a transaction is not set to Test, the transactions will be processed through the production environment.

PTE Access Exceptions (not supported):

ePACES; VeriFone POS; Audio Response Unit (ARU); and Paper

PTE Reminders

  • PTE has a strictly enforced limit of 2 files per day/per user and a limit of 50 claims per file submission
  • PTE is available to current trading partners (ETIN required)
  • Test remittances are produced according to the submitter's/provider's production method of delivery
  • PTE weekly cycle ends on Fridays and remittances are delivered the following week

For more information about ICD-10 implementation see the FAQs published at:

Questions may be directed to the eMedNY Call Center at (800) 343-9000 or via e-mail


Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at:

Providers wishing to listen to the current week's check/EFT amounts:
Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount).

Do you have questions about billing and performing MEVS transactions?
Please call the eMedNY Call Center at (800) 343-9000.

Provider Training: To sign up for a provider seminar in your area, please enroll online at: For individual training requests,
call (800) 343-9000 or e-mail:

Enrollee Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program: For current information on best practices in pharmacotherapy, please visit the following websites:

Need to change your address? Does your enrollment file need to be updated because you've experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment? Visit and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.)

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.