New York State Medicaid Update - October 2018 Volume 34 - Number 10

In this issue …

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Medicaid FFS Removing NDCs

Effective October 1, 2018, NYS Medicaid fee-for-service (FFS) will remove certain National Drug Codes (NDCs) from the formulary for which the corresponding manufacturers failed to update their Medicaid National Drug Rebate Agreement (NDRA), per Centers for Medicare & Medicaid Services (CMS) requirements.

On March 22, 2018, CMS made available the final notice CMS-2397-FN ( that announced changes to the NDRA. Manufacturers with an existing active NDRA(s) had until September 30, 2018, to complete, sign and submit the updated NDRA in order to continue participation in the Medicaid Drug Rebate Program (MDRP).

The impact of these formulary changes on Medicaid FFS members is minimal, as there is low utilization for affected NDCs and all NDCs that are being removed from the formulary have equivalent or alternative covered products. Pharmacy providers may need to utilize alternate manufacturers or in some cases, work with the prescriber to obtain a new prescription for an alternative product. Potential Labeler/Manufacturer terminations can be found here:

The following reject message will be returned for Medicaid FFS claims: NCPDP value "70"- Product/Service not Covered. This notice also applies to Medicaid Managed Care Plans that will communicate directly to their pharmacy networks.

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OMIG Issuing Controlled Substance Accumulation Letters to Pharmacy Providers and Prescribers

The Office of the Medicaid Inspector General's (OMIG) Recipient Restriction Program has begun sending Controlled Substance Accumulation Letters to pharmacy providers and prescribers informing them when OMIG has identified a recipient who has demonstrated a pattern of obtaining excessive quantities of controlled substance medications.

OMIG's Recipient Restriction Program regularly reviews recipient drug utilization for patterns of excessive drugs, duplicative drugs, and drugs that conflict with the care provided by another provider. Ongoing reviews have identified a trend in which recipients are filling their controlled substance prescriptions a few days early each month before exhausting all but a seven-day supply from previous prescriptions. As a result, over time, recipients may be accumulating significant quantities of controlled substance medications.

The educational letters serve to remind pharmacy providers and prescribers about their obligations under Title 10, Part 80, Rules and Regulations on Controlled Substances and to specifically highlight requirements with respect to Schedule II and certain other substances under 10 NYCRR 80.67(c), which states:

Except as provided for in subdivision (d) of this section, no such prescription shall be made for a quantity of substances which would exceed a 30-day supply if the substance were used in accordance with the directions for use, specified on the prescription. No additional prescriptions for a controlled substance may be issued by a practitioner to an ultimate user within 30 days of the date of any prescription previously issued unless and until the ultimate user has exhausted all but a seven days' supply of that controlled substance provided by any previously issued prescription.

In addition, OMIG recommends all pharmacy providers and prescribers regularly consult the New York State Prescription Monitoring Program (PMP) Registry prior to dispensing or prescribing controlled substances and report any discrepancies to the applicable agencies, as appropriate. Anyone who suspects potential Medicaid fraud or abuse can report it to OMIG by calling the fraud hotline at 1-877-873-7283 (1-877-87-FRAUD) or by filing the complaint online via OMIG's website at:

For additional information about OMIG's Controlled Substance Accumulation Letters, please contact the Restricted Recipient Program at(518) 474–6866.

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Pharmacy Pricing Policy – Submission of Usual and Customary (U&C) Price for Pharmacy Claims

Attention Pharmacy Providers: In accordance with 42 C.F.R. § 447.512(b), pharmacies must provide a Usual and Customary (U&C) price when submitting pharmacy claims for prescription and over-the-counter (non-prescription) items. The U&C price is the price charged to the general public, including applicable discounts (e.g. promotional discounts and discounted prices associated with loyalty programs) and is used to calculate the item's Medicaid reimbursement per New York State Social Services § 367-a.

Inaccurate U&C prices may result in incorrect Medicaid reimbursements. Knowingly submitting inaccurate U&C pricing may be considered fraudulent billing and can result in a civil penalty and damages under 31 U.S.C.S. § 3729(a)(1) and N.Y. State Fin. Law § 189(1), and exclusion from the Medicaid program under 42 U.S.C.S § 1320a-7(b)(6)(A).

Medicaid fee-for-service (FFS) payment methodology, which includes U&C price, can be found here: The U&C should be submitted in NCPDP field 426-DQ.

Any questions related to this policy can be addressed to:

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NY Medicaid EHR Incentive Program

The NY Medicaid Electronic Health Record (EHR) Incentive Program promotes the transition to EHRs by providing financial incentives to eligible professionals and hospitals. Providers who demonstrate Meaningful Use of their EHR systems are leading the way towards Interoperability, which is the ability of healthcare providers to exchange and use patient health records electronically. The ultimate goal is to increase patient involvement, reduce costs, and improve health outcomes. Since December 2011, over $930 million in incentive funds has been distributed through 35,836 payments to New York State Medicaid providers.

Since 2011, Eligible Professionals & Eligible Hospitals have received:

Number of Payments:Distributed Funds:

Unsure about your Medicaid Patient Volume (MPV)?

NY Medicaid EHR Incentive Program has developed a service allowing providers to request a summary of their Medicaid encounter data attributed to their National Provider Identifier (NPI). Encounter data may also be requested for an organization NPI. This report may be used to aid providers in preparing their attestation by providing the number of Medicaid patient encounters for the purposes of determining eligibility for the NY Medicaid EHR Incentive Program. To request a summary of Medicaid encounters, contact Make sure to include the provider name, NPI and calendar year for the requested data.

Numerator Data Request Form
NPI:<< NPI>>
Calendar Year:<<YEAR>>

Webinar Schedule October/November/December 2018

We've added a new webinar! Security Risk Analysis (SRA) is intended for Eligible Professionals who are attesting to Modified Stage 2 or Stage 3 for 2018.

Meaningful Use Modified Stage 2November 14, 201810:00am - 11:00am
December 7, 201812:00pm -   1:00pm
Meaningful Use Stage 3November 30, 201812:00pm -   1:00pm
December 20, 201811:00am - 12:00pm
Modified Stage 2 for New Meaningful UsersOctober 25, 20182:00pm -   3:00pm
November 2, 20182:00pm -   3:00pm
December 18, 201812:00pm -   1:00pm
2018 MU Public Health ReportingNovember 6, 201810:00am - 11:00am
December 4, 201810:00am - 11:00am
*NEW* Security Risk Analysis (SRA)October 30, 20189:00am - 10:00am
November 28, 20182:00pm -   3:00pm
December 12, 20189:00am - 10:00am

2017 MU Attestation Tutorial Series

NY Medicaid EHR Incentive Program has produced a series of MEIPASS tutorials to help you with your 2017 Modified Stage 2 or Stage 3 Meaningful Use Attestation. Click the links below, or see all of the tutorials here:

Customer Satisfaction Survey

The NY Medicaid EHR Incentive Program is looking for feedback. We want to continue to provide quality services to Medicaid providers throughout New York State so, we have developed and launched a new program survey. The survey is short (it takes less than 2 minutes to complete!) and we welcome your valuable insight. To complete the survey, click here:

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Find the following information and much more at

phone icon Questions? We have a dedicated support team ready to assist. Contact us at 877-646-5410, option 2 or

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The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
State of New York

Howard A. Zucker, M.D., J.D.
New York State Department of Health

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs