New York State Medicaid Update - December 2020 Volume 36 - Number 18

In this issue …

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.

Changes to Fee-for-Service Durable Medical Equipment Policy for Wheeled Mobility Guidelines and Criteria

Effective February 1, 2021, the fee-for-service (FFS) Durable Medical Equipment (DME) Policy for Wheeled Mobility Guidelines and Criteria will be updated to reflect the changes below. The changes clarify that manual and powered wheeled mobility equipment are approved by FFS Medicaid for members for use in the home and/or community. Three changes were identified in the current DME Procedure Code Manual under the Wheeled Mobility Guidelines/Coverage Criteria. The changes will alter the current wording "home and community" to "home and/or community".

Please Note: The emboldened(strong)/italicized(emphasized) text denotes the changes made to the specified areas of the manual. The modifications are as follows:

  1. General Clinical and Coverage Criteria for Wheeled Mobility Equipment (WME), Page 53, 11th bullet point: When a member presents for a medical evaluation for WME and SPC (Seating and Positioning Components), the sequential consideration of the questions, listed below, by ordering and treating practitioners provides clinical guidance for the ordering of one appropriate device to meet the medical need of treating and restoring the member´s ability to perform Mobility Related Activities of Daily Living (MRADLs). MRADLs include dining, personal hygiene tasks, and activities specified in a medical treatment plan completed in customary locations in the home and/or community. Please Note: New York State Medicaid funds and maintains one medically necessary manual mobility device to meet the member´s medical needs whether primarily used in the home, community, or as a back-up to the primary Power Wheelchairs (PWC).
  2. Manual Wheelchairs (MWC), Page 59, Criteria 3: The manual wheelchair supplied to the member for use in the home and/or community provides adequate access to these settings (e.g., between rooms, in and out of the home, transportation, and over surfaces).
  3. Power Mobility Devices (includes Power Operated Vehicles (POV) and Power Wheelchairs (PWC), Page 66, Criteria 12: The member´s home and/or community environment provides adequate access between rooms, in and out of the home, maneuvering space and over surfaces for the operation of the power wheelchair that is provided.

In addition to these changes, a modification will be made to the WME Documentation Requirements regarding the secure storage space necessary for wheeled mobility devices is in the member´s home, Requirement 6, Page 58: Prior to or at the time of delivery of a MWC, POV, or PWC, the supplier, practitioner, or case manager must perform an on-site evaluation of the member´s home to verify that the member can adequately maneuver the device that is provided considering physical layout, doorway width, doorway thresholds, and surfaces. The evaluation should also include a description of the secure storage space in the member´s home for the wheeled mobility device. Whether the WME is approved for the home and/or community, the WME provided must have an accessible secure storage space in the home. A written report of this evaluation should be available on request.

Questions

For questions regarding this update, contact the Bureau of Medical Review at (800) 342‑3005 or by email at OHIPMEDPA@health.ny.gov.

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Submission Guidance for Fee-for-Service Claims with Third Party Liability (Medicare or Other Insurance)

All New York State (NYS) Medicaid claim submissions should accurately reflect payments received from all other insurers (i.e., Medicare or other insurances) to allow correct calculation of Medicaid reimbursement. The Explanation of Benefits (EOB), along with other documentation supporting Medicare and third-party insurance reimbursement amounts, must be kept for audit or inspection. Such audit or inspection would be performed by the NYS Department of Health (Department), Office of the Medicaid Inspector General (OMIG), the Office of the State Comptroller (OSC), the NYS Office of the Attorney General and/or other state or federal agencies, for the period required by federal or state statute, regulation, policy or contract.

Additionally, for any claims submitted to NYS Medicaid with a zero-fill reimbursement from Medicare or other third-party insurers, providers must retain evidence that the claims were denied by the other insurers before seeking reimbursement from NYS Medicaid. Exceptions to this policy would be for claims reflecting items or services that are statutorily not covered by the Medicare program. Providers may bill NYS Medicaid directly without receiving denials from Medicare for these exceptions. Providers are responsible for retaining the statutory exemption from Medicare for audit or inspection.

The Department reviewed zero-filled claim submissions and collected information from providers for analysis of claims. These reviews and subsequent analysis are meant to assist providers with proper claim submission and appropriate use of zero-fill. For further information regarding the primary issues that were found during the review, please reference to eMedNY´s Submission Guidance for Claims with Third Party Liability (Medicare or Other Insurance) document.

Questions and Additional Information:

  • General questions regarding claims submission should be directed to the eMedNY Call Center at (800) 343‑9000.
  • Questions regarding specific medical pended claims should be directed to the Bureau of Medical Review, Pended Claims Unit at (800) 342‑3005 (option 3).
  • Questions regarding specific dental pended claims should be directed to the Bureau of Dental Review, Pended Claims Unit at (800) 342‑3005 (option 2).

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Help Stop the Spread of COVID-19 by Sharing the New COVID Alert NY App

New York State Department of Health´s new COVID Alert NY app is gaining participation with more New Yorkers every day. Please keep sharing the COVID Alert NY app information with partners and consumers. Together everyone can help stop the spread of this virus.

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Medicaid Consumer Fact Sheets Now Available

New York State Department of Health (DOH) Office of Health Insurance Programs has created new Medicaid consumer fact sheets focused on chronic health conditions. Each fact sheet provides information regarding how a condition can be prevented and managed, as well as relevant Medicaid benefits that can be used to help enrollees stay healthy. Fact sheets are currently available on the topics of diabetes, high blood pressure, asthma control and HIV-PrEp (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), in the following languages: English, Spanish, Traditional Chinese, Russian, Haitian Creole, Bengali and Korean. Fact sheets on additional health topics will be produced in the coming weeks and will be posted, along with the existing fact sheets, on the Medicaid Redesign Team (MRT) II Policies and Guidance web page.

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NY State of Health Open Enrollment — There is Still Time to Get New Yorkers Enrolled in 2021 Coverage

NY State of Health is reminding New Yorkers applying for Qualified Health Plan coverage that it´s not too late to enroll in a health plan effective February 1, 2021. Consumers must enroll by January 15 for coverage starting February 1. For those who enroll after January 15, coverage will begin on March 1, 2021. Individuals should enroll now by visiting the NY State of Health website. The Open Enrollment Period ends on January 31, 2021.

Enrollment is open for all NY State of Health programs: Medicaid, the Essential Plan, Child Health Plus, and Qualified Health Plans. Most consumers who enroll through NY State of Health are eligible for financial assistance to lower the cost of their coverage. Due to the ongoing COVID-19 public health emergency, consumers already enrolled in Medicaid, Child Health Plus, or the Essential Plan will have their coverage continued automatically and do not need to renew at this time.

Get Help Enrolling:

Consumers interested in learning more about their coverage options can:

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Attention Ambulance Services: The Centers for Medicare and Medicaid Services Emergency Triage, Treat, and Transport (ET3) Model

The Centers for Medicare and Medicaid Services (CMS) has invited twenty-five (25) New York State (NYS) ambulance suppliers and providers to participate in its Emergency Triage, Treat, and Transport (ET3) Model. Pages four (4) through five (5) of the list of invited ambulance services contain the NYS invitees. The CMS ET3 Model aims to reduce expenditures and preserve or enhance quality of care by:

  • Providing person-centered care, such that beneficiaries receive the appropriate level of care delivered safely at the right time and place while having greater control of their healthcare through the availability of more options.
  • Encouraging appropriate utilization of services to meet health care needs effectively.
  • Increasing efficiency in the Emergency Medical Services (EMS) system to more readily respond to and focus on high-acuity emergency cases.

Currently, Medicare only pays for ground ambulance services when beneficiaries are transported to specific types of facilities. In an emergency setting, this is most often a hospital emergency department (ED), even when an alternative treatment option may be more appropriate. As part of the ET3 Model, CMS (and NYS Medicaid) will be testing two new ambulance payments. While continuing to pay for emergency transportation of a Medicare beneficiary to a hospital ED, under the ET3 Model, Medicare will also pay participating ambulance suppliers and providers to:

  • Transport a beneficiary to an alternative destination (such as an urgent care clinic, federally qualified healthcare center, hospital outpatient department, freestanding clinic or a physician´s office which over time should include a priority to transport to the patient´s medical home/PCP as possible), or;
  • Initiate and facilitate treatment in place by a qualified health care practitioner, either in-person on the scene, or via telehealth. In this context, a qualified health care practitioner is limited to a physician, physician´s assistant, nurse practitioner or, when appropriate for the patient, a licensed mental health care professional.

Upon arriving on the scene of a 911 call, participating ambulance suppliers and providers may triage beneficiaries to one of the ET3 Model interventions. This requires the participating ambulance suppliers and providers to partner with alternative destinations and with qualified health care practitioners to deliver treatment in place (either on-the-scene or through telehealth). A patient can always choose to be brought to an ED if he or she prefers.

Any ambulance supplier or provider approved to participate in the ET3 Model by CMS, may apply to NYS Medicaid for participation in a Medicaid parallel ET3 Model. The NYS Medicaid ET3 Model will mirror both the timing and the tenets of the CMS ET3 Model.

  • The applicable base rate and mileage payment will be made for the transportation of a beneficiary to an alternative destination (such as an urgent care clinic, federally qualified healthcare center, hospital outpatient department, freestanding clinic or a physician´s office).
  • The applicable base rate payment will be made when an approved ambulance supplier or provider initiates and facilitates treatment in place by a qualified health care practitioner, either in-person on the scene, or via telehealth.
  • Payment to a qualified heath care practitioner or an alternative destination will be made separately, and in accordance with the appropriate NYS Medicaid fee schedule or plan negotiated payment.

To apply for participation in the NYS Medicaid ET3 Model, a CMS-approved ambulance supplier or provider must submit:

  • Written confirmation of the CMS approval for its participation in the CMS ET3 Model. Ambulance providers or suppliers that have not been approved by CMS are ineligible for participation in NYS Medicaid ET3 Model.
  • A copy of the submitted CMS ET3 Model application and all supporting documents.
  • An affirmation, signed by the chief executive officer of the organization, agreeing to provide the NYS Department of Health (DOH) with copies of all quality improvement and other reports required by CMS.
  • Evidence of outreach to Medicaid managed care organizations (MCOs) in the region to coordinate network and payment issues for both treat in place (including telehealth) and alternative destinations.

All applications and any questions on the Medicaid component of the ET3 Model may be submitted electronically to medtrans@health.ny.gov.

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Convenient Healthcare Links Available on eMedNY Website

The eMedNY website contains a collection of other "Healthcare related Links" that direct providers to helpful resources. Providers can easily find these Healthcare related resources on the eMedNY website by selecting the "Contacts" tab and then "Healthcare-related Links" from the drop-down selection list. The "Healthcare-related Links" page includes links to Federal websites, various New York State websites, Other (Medicaid) State Links, and general Health Organizations/Associations.

The convenient location of these links on the eMedNY website can be helpful to providers who need to connect to other websites such as New York State Departments including those listed below:

For additional assistance navigating the eMedNY website, please contact the eMedNY Call Center at (800) 343‑9000.

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Reminder: Sign Up for eMedNY Training Webinars

eMedNY offers various types of training webinars for providers and their billing staff. Webinars are conducted online, so that providers may join the meeting via a computer and telephone. No travel is necessary.

Webinar registration is fast and easy. To register, please view the list of topics, descriptions and available session dates at the Provider Training web page. Providers are reminded to review the webinar descriptions carefully to identify the webinar appropriate for their specific training needs.

Questions regarding training webinars should be directed to the eMedNY Call Center at (800) 343‑9000.

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Reminder: Fee-for-Service Early Refill Guidance to Pharmacies During the Continued Disaster Emergency for COVID-19

During the Declared Disaster Emergency for COVID-19 in New York State (NYS), pharmacies may provide an early refill for members in need of medications due to quarantine or outbreak as outlined below and under the Early Fills section of the April 2, 2020 guidance. Pharmacies must document the use of this override in pharmacy processing systems as early fills related to the Declared Disaster Emergency. Uses of this override are monitored by the NYS Department of Health (DOH). If pharmacies have been given permission by DOH to use this override for any other purpose, the pharmacies must document. The documentation may include reference numbers provided by DOH in the pharmacies processing systems in lieu of documenting the calls on the prescriptions. Uses of the override are subject to audit and recovery by the NYS Office of Medicaid Inspector General (OMIG). Previous guidance on early fills can be found in the January 2015 and January 2018 Medicaid Update publications.

Questions and Additional Information:

  • Billing questions should be directed to the eMedNY Call Center at (800) 343‑9000.
  • Policy questions should be directed to the pharmacy mailbox at ppno@health.ny.gov or via phone at (518) 486‑3209.
  • Medicaid Managed Care questions regarding policy and billing guidance for early fill should be directed to the member´s Medicaid Managed Care plan.

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Compound Policy: A Reminder and Clarification

The purpose of this guidance is to remind pharmacies that compounded prescription medications billed to New York State (NYS) Medicaid must follow the compound policy as updated in the February 2014 and November 2018 Medicaid Update publications. Additional guidance is given below. The Department of Health (DOH) has made and will continually make formulary updates and system enhancements to support this policy. The Office of the Medicaid Inspector General (OMIG) will continue to review claims for Policy adherence.

NYS Medicaid acknowledges the need for traditional extemporaneous compounding to customize a drug prescribed for a NYS Medicaid covered medically accepted indication which the therapeutic amounts, combinations, and route of administration are Food and Drug Administration (FDA) approved or compendia supported and there are no suitable commercially available products within the drug class.

The NYS Medicaid compound policy is further clarified below:

  • Only the dispensing pharmacy may prepare the prescribed compounded prescription.
  • Dispensing outsourced prepared compounds is not allowable.
  • Compounds trademarked by pharmacies are not coverable.
  • Refills of compounds must be specifically requested by the patient or patient´s authorized agent before the item is prepared.
  • Compounds may not be made to bypass the criteria within the NY Medicaid Fee For Service Program.
  • Compounds may not be made with or to replace drug products removed from the marketplace due to safety reasons.
  • Active FDA-approved ingredients submitted on compound claim must be otherwise available on the NYS Medicaid List of Reimbursable Drugs.
  • Compounds may not contain drugs or be made for NYS Medicaid excluded indications as per the Social Security Act §1927(d)(2) including but not limited to drugs to treat weight loss or sexual dysfunction or for cosmetic purposes.
  • Compounds may not be made in therapeutic amounts or combinations not FDA-approved, or compendia-supported for use.
  • Compounds may not be made to add coloring, flavoring, perfumes or other non-active ingredient additives to a commercially available product.
  • Submitted compound claims may not include packaging materials or containers, syringes, or other items utilized or necessary in the preparation of final compounded product.
  • Compounds must be adjudicated with the appropriate and matching final compounded product route code for the dosage form.
  • Prepared compounds that mimic a commercial product must include on the prescription and in the members medical chart documentation of the reason for compounding (i.e., sensitivity or contraindication to dyes, preservatives, or fillers or lack of availability of a commercial product).
  • The FDA-approved, or compendia supported use and dose of an ingredient must match the compound´s intended therapeutic use.
  • Reconstitution per product labeling is not considered a compound whether it comes as a kit or requires additional supplies.
  • All NYS Medicaid policies, NYS and federal laws apply.

Topical

Examples of non-covered topical compounds are those made:

  • with ingredients not FDA approved, compendia supported, or excluded from NYS Medicaid coverage for topical use, or
  • for foot baths, other soaks, or irrigations.

Oral

Examples of non-covered oral compounds are those made:

Parenteral

Examples of non-acceptable parenteral compounds are those:

  • inconsistent with sterile compound criteria as required by State or federal law or regulation (8NYCRR Part 29.2 (13)), or
  • made to simply dilute, reconstitute, or otherwise prepare a medication for infusion per it´s labeling, or
  • products made for nutrition or hydration. Providers can refer to the correct billing guidance for these products in the NYS Medicaid Program Pharmacy Procedure Codes document.

Questions and Additional Information:

  • Questions regarding this policy should be directed to the Medicaid Pharmacy Policy unit at (518) 486‑3209 or via email at ppno@health.ny.gov.
  • Questions regarding enteral, parenteral or compound billing should be directed to the eMedNY Call Center at (800) 343‑9000.

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

Andrew M. Cuomo
Former Governor
State of New York

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

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs