New York State Medicaid Update - December 2018 Volume 34 - Number 12

In this issue …

|top of page|

Children and Family Treatment and Support Services

Children's Medicaid Health and Behavioral Health System Transformation

Beginning January 1, 2019, contingent on anticipated federal approval, coverage becomes available in fee-for-service (FFS) Medicaid and Medicaid Managed Care (MMC) for three new Medicaid services, collectively titled Children and Families Treatment and Support Services (CFTSS):

Other Licensed Practitioners (OLP) which includes:

  • Licensed Evaluation/Assessment, including Treatment Planning
  • Psychotherapy
  • Crisis Intervention Activities

Community Psychiatric Support and Treatment (CPST) which includes:

  • Intensive Interventions (counseling)
  • Crisis Avoidance (counseling)
  • Intermediate Term Crisis Management (counseling)
  • Rehabilitative Psychoeducation (not involving counseling)
  • Strengths Based Service Planning (not involving counseling)
  • Rehabilitative Supports (not involving counseling)

Psychological Rehabilitation Supports (PSR), which includes promoting personal and community competence in the following areas:

  • Social and Interpersonal Skills
  • Daily Living Skills
  • Community Integration

Each CFTSS is available to any child less than 21 years of age who meets the medical necessity criteria for the service.

To deliver CFTSS, a provider must receive a designation from the State. To be reimbursed for services delivered to a child in an MMC Plan, a provider must participate in that plan's network* (or, a single case agreement between the plan and the provider may be arranged to treat one individual, without the provider joining the plan's network). More information about provider designation, including instructions to apply for designation can be found at:

Information about billing CFTSS can be found at:, and by selecting "Billing Guidance" under the heading 'Children's Behavioral Health' in the left-hand navigation bar.

*Note: Behavioral Health services, including CFTSS, are delivered on a FFS basis for children less than 21 years of age who are Supplemental Security Income (SSI) or Supplemental Security Income-Related (SSI-R). CFTSS claims for these children should be submitted to FFS Medicaid, regardless of the child's plan enrollment status. Check ePaces for a message indicating "mental health carve out" to identify these children.

|top of page|

New York State's Medicaid Doula Pilot Program

On April 23, 2018, the State announced a comprehensive initiative to target maternal mortality and reduce racial disparities in health outcomes. This initiative includes a Medicaid pilot program to cover doula services. A doula is a non-medical birth coach who provides physical, emotional, and informational support to pregnant clients before, during, and after childbirth. Doulas have been shown to improve health outcomes in both mothers and babies.

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans will launch a pilot program to reimburse doula services beginning on March 1, 2019, for both FFS and MMC members residing in Erie County and specific ZIP codes in Kings County. The ZIP codes included in the doula pilot are outlined in the doula provider manual. Policy information regarding the doula pilot program (e.g., provider enrollment, scope of services, and billing guidance) can be found at: Medicaid will reimburse doulas for providing up to three (3) prenatal visits and four (4) postpartum visits in addition to support during the labor and delivery process.

NYS Medicaid Doula Enrollment

Doulas must enroll in NYS Medicaid as an independent service provider. When providing services to an MMC Plan member, please follow guidelines specific to the member's MMC Plan. However, all doulas providing services to MMC Plan members must first enroll in NYS Medicaid prior to enrolling in the Plan. Please refer to Section 1 – Provider Enrollment in the doula provider manual for specific doula requirements for enrolling in the Medicaid program.

Additional information regarding the NYS Medicaid enrollment process and application forms can be found at: On this site there are several areas that include helpful enrollment information. On the right-hand side, under 'Provider List Filter', there is a link for "DOULA (Pilot Program)" that includes doula-specific information regarding enrollment.

MMC Billing

Providers participating in MMC should contact the individual health plans to determine how each MMC plan will implement this policy. Questions regarding MMC reimbursement and/or documentation requirements should be directed to the member's MMC plan.

FFS Billing

Providers, please check the doula fee schedule for current reimbursement rates. The web page is currently under construction but the doula fee schedule will be found at the following link: by clicking on "Fee Schedule." General billing instructions can be found at:

Medicaid Updates

Providers are encouraged to read the Medicaid Update publication for the most recent NYS Medicaid policy updates, including new information and policy related to the doula pilot program. The Medicaid Update archive can be found at:

Provider Communications

Periodically, communications will be posted on the doula provider manual website. Please refer to the following web page to remain current with doula provider communications:


The eMedNY LISTSERV is a Medicaid mailing system that offers providers the opportunity to receive a variety of notifications from eMedNY. The email notifications are provided as a free service to subscribers and include information on provider manual updates, fee schedules, edit status changes, billing requirements, and many other helpful notices. Please follow the link provided below to sign up and receive notification of updates to manuals, communications, and other pertinent information by provider type:


  • Questions related to the NYS Doula Pilot Program should be directed to
  • Policy questions regarding Medicaid FFS may be directed to the Office of Health Insurance Programs, Division of Program Development and Management at (518) 473–2160.
  • Questions regarding Medicaid FFS billing or claims should be directed to the eMedNY Call Center at (800) 343–9000.
  • Questions regarding MMC reimbursement and/or documentation requirements should be directed to the member's MMC plan.

|top of page|

Important Change: Fidelis Care to Provide Family Planning and Reproductive Health Benefit

Effective January 1, 2019, Fidelis Care will include family planning and reproductive health services in the benefit package for Medicaid members. Previously Medicaid fee-for-service (FFS) had provided this benefit for Fidelis members.

As a result, participating Fidelis Care providers should bill these services to Fidelis instead of Medicaid FFS, effective January 1, 2019.

Coverage will include:

  • birth control drugs and devices, including IUDs, diaphragms, and other kinds of birth control;
  • emergency contraception;
  • sterilization for men and women;
  • pregnancy testing;
  • an abortion that you and your doctor agree is needed; and
  • HIV and sexually transmitted disease (STD) testing, treatment and counseling. Screenings for cancer and other related problems are also included.

For information on pharmacy formulary coverage visit the NY State Medicaid Managed Care Pharmacy Benefit Information Center website at: Questions can be directed to Member Services at 1-888-FIDELIS (1-888-343-3547) (TTYL: 711) Monday through Friday from 8:30 a.m. to 6:00 a.m.

|top of page|

New York Medicaid EHR Incentive Program Update

Distribution to Eligible Professionals & Eligible Hospitals Since EHR Program Start in 2011
Number of Payments:Distributed Funds:

The New York Medicaid Electronic Health Record (EHR) Incentive Program promotes the transition to EHRs by providing financial incentives to eligible professionals (EPs) and hospitals. Providers who demonstrate Meaningful Use (MU) 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.

How does using EHR promote interoperability?

  • Providers are ensuring that Protected Health Information (PHI) is private and secure and easily useable, by the patient and their family, and by other providers - current and future;
  • There is full and easy access to all electronic health information that is authorized for such; and
  • There is protection against information blocking – when a provider, vendor, or IT developer knowingly and unreasonably interferes with the exchange and use of electronic health information. Examples are: fees that make data exchange cost prohibitive; organizational policies that prohibit the exchange of information; or when patients or health care providers become "locked in" to a specific technology or health care network because data is not portable.

A Look Back at Calendar Year 2018

As we finish out the year, we wanted to highlight some of what's happened in 2018:

  • There has been a complete transition back to MEIPASS for PY2017 attestations. We no longer require the hybrid workbook process that was used for 2015 and 2016 MU attestations.
  • Electronic signatures were implemented in MEIPASS for PY2017 attestations and forward.
  • New video tutorials for the MEIPASS attestation process were added to our website.
  • We created new and updated webinars (e.g., Security Risk Analysis (SRA) and Public Health Reporting).
  • Finally, we closed out all PY2016 EP attestations! There were 3,358 AIU Payments and 4,032 MU Payments for a total of 7,390 EP payments for PY2016.

A Look Ahead to Payment Year 2019

The Centers for Medicare & Medicaid Services (CMS) recently published rulemaking that impacts the NY Medicaid EHR Incentive Program and aligns it with the Merit-based Incentive Payment System (MIPS). The MU requirements for all EPs for 2019 include:

  • The exclusive use of 2015 Edition Certified EHR Technology.
  • EPs must attest to Stage 3 objectives and measures. Please note, the thresholds for Stage 3 Objective 6 Coordination of Care measures 1 and 2 will not increase. These measures will remain at more than five percent for 2019 MU and the remainder of the program.
  • There is a minimum 90-day EHR reporting period.
  • There are six clinical quality measures (CQM), including one outcome or high priority measure.
  • EPs must report CQM for the entire calendar year. Also, the eCQI Resource Center has posted the 2019 CQM that align with MIPS which can be found at: EPs may be able to participate in both the NY Medicaid EHR Incentive Program and MIPS.

Why You Should Complete the NY Medicaid EHR Incentive Program Customer Satisfaction Survey

  • We want to know more about our audience so that we can provide you with the information and support that best suits your needs.
  • We want to know the topics that you would like to see highlighted. We created SRA Webinar based on EP feedback.
  • We want feedback on our services. Tell us what you think of our support line, website, and webinars.
  • The survey is short – it takes less than two minutes to complete!

We welcome your valuable insight. To complete the survey, visit the following website at:

Webinar Schedule January 2019 – February 2019

Webinar Date Time
Meaningful Use Modified Stage 2
February 4, 2019 2:00 p.m. -   3:00 p.m.
Meaningful Use Stage 3 January 24, 2019 10:00 a.m. - 11:00 a.m.
February 19, 2019 2:00 p.m. -   3:00 p.m.
2018 MU Public Health Reporting January 18, 2019 10:00 a.m. - 11:00 a.m.
February 13, 2019 12:00 p.m. -   1:00 p.m.
Security Risk Analysis (SRA) January 22, 2019 2:00 p.m. -   3:00 p.m.
February 22, 2019 10:00 a.m. - 11:00 a.m.

NY Medicaid EHR Incentive Program Post-Payment Audit Education Series

NY Medicaid EHR Incentive Program has produced a series of Post-Payment Audit Educational tutorials to help you prepare for Modified Stage 2 or Stage 3 Meaningful Use Attestation.

  • Part 1: Audit Process Overview
  • Part 2: Understanding the Audit Notification Email – Adopt, Implement, Upgrade (AIU)
  • Part 3: Understanding the Audit Notification Email – Meaningful Use
  • Part 4: Completing the Medicaid Patient Volume Spreadsheet
  • Part 5: Submitting Documentation

Visit our Website

Find the following information and much more at:

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

|top of page|

Medicare Advantage Supplemental Dental Insurance

A recent Office of the State Comptroller (OSC) audit determined that dental providers do not always bill a recipient's Medicare Advantage Plan (Part C) prior to billing Medicaid. Medicaid requires that providers exhaust all existing benefits prior to billing Medicaid. It is the provider's responsibility to bill the Plans or the Plans' Dental Benefit Administrators for dental services, on behalf of dual eligible recipients, covered by a Plan that offers supplemental dental insurance.

Please review the June 2010 Medicaid Update on Eligibility and Benefit Verification for Beneficiaries Enrolled in Medicare Health Plans and Medicaid.

Questions regarding this policy should be directed to:

Transportation Provider Reminder: Vehicle Ownership for Exemption for Categories of Service 0605 and 0609

At present, the Department of Health requires Medicaid transportation providers to own all vehicles outright and to be personally responsible for insuring and maintaining their vehicles as indicated in the Transportation Manual - Policy Guidelines section "Policy Regarding Vehicle Ownership or Leasing and Insurance." The Department continues to prohibit subcontracting of Medicaid transports.

Medicaid transportation providers enrolled in categories of service 0605 Livery/Black Car (NYC Only) or 0609 Transportation Network Company/High Volume For-Hire-Service are exempt from these requirements. Under these two categories of service, providers may employ drivers who own and operate their own vehicles. Please note, Medicaid transportation providers that are enrolled in these categories of service must comply with all local municipal requirements, including being licensed by the applicable Taxi and Limousine Commission governing the service area, and with all requirements of the NYS Department of Motor Vehicles.

Questions related to this policy should be emailed to

|top of page|

Tobacco Cessation Counseling by Dental Providers

In an effort to assist in Medicaid enrollees' compliance with the recent implementation of the United States Department of Housing and Urban Development (HUD) Smoke-Free Housing Policy and to reduce patient risks of developing tobacco-related oral diseases, along with improving outcomes of certain dental therapies, this is a reminder that tobacco cessation counseling is a covered dental benefit through the New York State Medicaid Dental Plan under code "D1320". Dental settings provide a highly effective environment for tobacco use recognition, prevention, and cessation counseling and can be implemented by a licensed dentist or by a licensed hygienist who is supervised by the dentist. Additional guidelines and criteria for billing can be found on Pages 33-34 of the NYS Medicaid Program Dental Policy and Procedure Code Manual at:

For further assistance in billing guidelines and criteria or other questions related to dental policy, please contact

|top of page|

Reminder: Ordering, Prescribing, Referring, Attending (OPRA) Prescription Requirements for Unlicensed Providers Only

Attention Pharmacy Providers: A provision of the Affordable Care Act (ACA) and federal regulations (42CFR 455.410) requires enrollment for physicians and other healthcare professionals when ordering/prescribing/referring/attending (OPRA) services are provided under the Medicaid state plan or under a waiver of the state plan. The requirement also applies to licensed providers prescribing for Medicaid beneficiaries residing in Long Term Care facilities and for services rendered through Medicaid Managed Care (MMC).

Effective January 1, 2014, as stated in the December 2013 Special Edition Medicaid Update, editing was put in place to reject claims submitted to Medicaid fee-for-service (FFS) with a non-enrolled licensed prescriber. Pharmacies were given permission to use the OPRA override temporarily to allow licensed physicians adequate time to enroll. The allowance for using the OPRA override for non-enrolled licensed prescribers ended in August 2014. All licensed prescribers, whether they are billing or non-billing, must be enrolled in the NYS Medicaid program in order for the pharmacy to successfully submit and bill the claim.

If pharmacies receive a claim rejected with NCPDP Reject Code 56 "NON-MATCHED PRESCRIBER ID", it means the prescriber is not enrolled in NYS Medicaid. eMedNY users will see Edit 02218 "PRESCRIBING MMIS PROVIDER ID CANNOT BE DERIVED". Prescriptions and fiscal orders cannot be submitted for reimbursement to NYS Medicaid when the licensed prescriber is not enrolled in NYS Medicaid. As noted on Page 16 of the August 2014 Medicaid Update, the OPRA override should be used only for unlicensed providers legally able to prescribe.

The use of an override to bypass this edit for a licensed provider is not permissible. Pharmacies should not attempt to override rejections for a non-enrolled licensed provider on their own, including any overrides in the submission clarification code field. All overrides are subject to recovery of payment. The only option available when your pharmacy is presented with a prescription or fiscal order written by a licensed, non-enrolled prescriber for a Medicaid member is to obtain a new prescription from an enrolled provider. For questions regarding this policy providers may email the pharmacy mailbox at: , or call(518) 486–3209.

|top of page|

Medicaid Pharmacy Prior Authorization Programs Update

On September 20, 2018, the New York State Medicaid Drug Utilization Review (DUR) Board recommended changes to the Medicaid pharmacy prior authorization programs. The Commissioner of Health has reviewed the recommendations of the Board and has approved changes to the Preferred Drug Program (PDP) within the fee-for-service (FFS) pharmacy program.

Effective December 6, 2018, prior authorization (PA) requirements will change for some drugs in the following PDP classes:

  • Fluoroquinolones - Oral
  • Pulmonary Arterial Hypertension (PAH) Oral Agents, Other
  • Central Nervous System (CNS) Stimulants
  • Helicobacter pylori Agents
  • Immunomodulators – Systemic
  • Anticholinergics/Chronic Obstructive Pulmonary Disease (COPD) Agents

The following therapeutic class will be added to the Preferred Drug List (PDL):

  • Anti-inflammatories/Immunomodulators - Ophthalmic

The following parameters will be implemented to ensure appropriate utilization:

  • Products for the prevention of migraine headaches:
    • Step Therapy: trial of two (2) Federal Drug Administration(FDA)-approved migraine prevention agents prior to a calcitonin gene-related peptide (CGRP) receptor antagonist.
    • Quantity Limit: maximum of two (2) prefilled syringes/autoinjectors per thirty (30) days for erenumab.

For detailed information on the above DUR Board recommendations, please refer to the meeting summary available at: For the most up-to-date information on the Medicaid FFS Pharmacy PA programs, please refer to the PDL available at:

To obtain a PA, please call the PA clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain a PA.

Medicaid-enrolled prescribers with an active e-PACES account can initiate PA requests through the web-based application PAXpress®. The website for PAXpress is PAXpress® can also be accessed through the eMedNY website at:, as well as Magellan Medicaid Administration's website at:

|top of page|

Reminder: 340B Providers, Covered Entities, Contract Pharmacies, and Third-Party Administrators

Please be advised: 340B drug claims submitted to Medicaid via the National Council for Prescription Drug Programs (NCPDP) D.0 format are required to be properly identified as 340B for both fee-for-service (FFS) and Medicaid Managed Care (MMC) members, and submitted at the 340B acquisition cost by invoice to the provider for FFS members, net any manufacturer discounts and/or other price reductions.

Accordingly, all 340B claim submissions should be correctly identified as such on the first transmission. However, if claims are being identified as 340B through reversals/resubmissions, the reversals/resubmissions should be completed within 45 days of the end of the quarter.

Please note that in FFS, resubmissions of claims are subject to the 90-day timely filing requirement. For 340B claims that are not properly identified within the 90-day timely filing window, the resubmitted claim will be denied for untimely filing and/or prior authorization.

For 340B claims that were not properly identified in a timely manner and for which NYS Medicaid has taken a rebate, the Covered Entity is liable to the drug manufacturer for the 340B discount per section 340B(a)(5)(D) of the Public Health Services Act, which can be found at:

The following fields are required on Medicaid 340B drug claims submitted in the NCPDP format:

Field Medicaid Primary Claim Medicaid Secondary Claim
(Primary: Medicare; Commercial)
420-DK, Submission Clarification Code (SCC) 20 20
423-DN, Basis of Cost Determination (BCD)* 08 No Requirements Specific to Medicaid
409-D9, Ingredient Cost Submitted* 340B Acquisition Cost No Requirements Specific to Medicaid
426-DQ, Usual and Customary Cost (U&C)** Lowest Net Charge to Cash Customers Lowest Net Charge to Cash Customers

*MMC plans should be consulted on their requirements for this field.

**U&C is defined as the lowest price charged to the general public after all applicable discounts, including promotional discounts and discounted prices associated with loyalty programs.

Note: All 340B claims are subject to audit and investigation; in addition, claims improperly identified as 340B and/or claims with unsubstantiated Acquisition Cost may be considered fraudulent claims.


|top of page|

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