New York State Medicaid Update - June 2021 Volume 37 - Number 8

In this issue …

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New York State Medicaid Expansion of Coverage for Colorectal Cancer Screening

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans [inclusive of Mainstream MMC Plans, HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs), as well as Health and Recovery Plans (HARPs)] have expanded current colorectal cancer screening coverage to include enrollees 45 to 49 years of age. This expansion is in response to recently updated recommendations by the United States Preventive Services Task Force (USPSTF). New information suggests earlier screening has a moderate net benefit and should be considered for individuals at average risk for colorectal cancer. The USPSTF continues to state, with high certainty, that screening for colorectal cancer in individuals 50 to 75 years of age have substantial net benefit. For additional information regarding colorectal cancer screening, providers can visit the USPSTF Colorectal Cancer: Screening web page.

Colorectal cancer is the third leading cause of cancer-related death in NYS, with almost 3,000 deaths reported in the state annually. Studies show that early detection can increase the five-year survival rate by as much as 75 percent. All Medicaid members between 45 to 75 years of age at average risk for colorectal cancer should be offered screening with one of the recommended screening test options. Screening members at high risk for colorectal cancer should be done sooner than screening of average risk individuals and should be based on clinical decision. Although cancer screening rates have increased over the last few years, it is estimated almost 30 percent of NYS residents between 50 to 75 years of age are not up to date with their colorectal cancer screening.

NYS Medicaid providers should notify all their adult patients about their risk for colorectal cancer and discuss screening test options with them. Studies show that patients are more likely to be screened for colorectal cancer if they are offered test options. Providers, taking patient preferences into consideration, may order the most appropriate colorectal cancer screening methods from Table 1. The recommended frequencies listed in Table 1 are for patients considered to be of average risk of developing colorectal cancer.

Table 1: Colorectal Cancer Screening Methods for Patients Considered to be of Average Risk
MethodRecommended Frequency
Fecal Immunochemical Test (FIT) or High Sensitivity Fecal Occult Blood Testing (FOBT)once annually
FIT-DNA* (e.g. Cologuard)once every three years
Computed Tomography Colonography (CTC)once every five years
Flexible Sigmoidoscopy (SIG)once every five years
Colonoscopyonce every ten years
SIG with FITonce every ten years (SIG), plus once every year (FIT)

*DNA - deoxyribonucleic acid, in this case based from stool and any blood shed therein.


  • The colorectal cancer screening methods included in Table 1 may be used for individuals considered to be at high risk. In general, however, screening with colonoscopy is the preferred method for most individuals at high risk for colorectal cancer.
  • More frequent colorectal cancer screening methods may be considered medically necessary for individuals considered to be at high risk of developing colorectal cancer.
  • It is important to discuss with patients that positive results from the screening methods outlined in Table 1, other than colonoscopy, may result in the need for diagnostic colonoscopies.
  • Colorectal cancers should be considered possible diagnoses in patients (regardless of age) presenting with blood in their bowel movements, changes in bowel habits, abdominal pains, weight losses, or unexplained anemias. In such situations, the USPSTF and the American Cancer Society (ACS) recommend clinical decision making to determine whether diagnostic colonoscopies should be performed.
  • NYS Medicaid considers colorectal cancer screening by any method not listed above experimental and investigational at this time.

Questions and Additional Information:

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Reminder: Sign Up for eMedNY Training Webinars

eMedNY offers several online training webinars to providers and their billing staff, which can be accessed via computer and telephone. Valuable provider webinars offered include:

  • ePACES for: Dental, Durable Medical Equipment (DME), Free-Standing and Hospital-Based Clinics, Institutional, Physician, Private Duty Nursing, Professional (Real-Time), Health Homes, Nursing Homes, and Transportation
  • ePACES Dispensing Validation System (DVS) for DME
  • ePACES Dispensing Validation System (DVS) for Rehabilitation Services
  • eMedNY Website Review
  • Medicaid Eligibility Verification System (MEVS)
  • New Provider / New Biller

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


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

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

As more New Yorkers download the New York State Department of Health's COVID Alert NY app every day, providers are encouraged to continue 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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Provider Quick Reference Guide Available on eMedNY

Providers in need of contact information related to eMedNY and the NYS Medicaid Program can find the pertinent phone number, website or email address in the Provider Quick Reference Guide arranged by the following (and additional) topics:

  • Billing Questions
  • Provider Enrollment
  • Member Eligibility
  • Utilization Threshold Override Applications
  • Check Amount Inquiry
  • Prior Approval (PA)
  • Fraud and Abuse
  • Medicaid Managed Care (MMC)
  • NYS Department of Health (DOH) Medicaid Update Newsletter

The Provider Quick Reference Guide also contains a link to a comprehensive list of frequently used eMedNY mailing addresses and information on Expedited/Priority mailing.


All questions regarding the Provider Quick Reference Guide should be directed to the eMedNY Call Center at (800) 343‑9000.

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Medicaid Consumer Fact Sheets Now Available

Following a recommendation from the Medicaid Redesign Team (MRT) II, the New York State (NYS) Department of Health (DOH) Office of Health Insurance Programs (OHIP) created Medicaid consumer fact sheets focused on chronic health conditions. Each fact sheet provides information regarding how a condition can help be prevented or managed, as well as relevant Medicaid benefits that can be used to help members stay healthy. Topics include sickle cell disease, diabetes, high blood pressure, asthma control, HIV-PrEP (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), and smoking cessation. Fact sheets can be found on the MRT II Policies and Guidance web page and are available in English, Spanish, Traditional Chinese, Russian, Haitian Creole, Bengali, and Korean. The most recently added Sickle Cell Disease fact sheet is also available in Simplified Chinese, Polish, Yiddish, Arabic, and Italian.

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NY State of Health: Higher Income New Yorkers May Now Qualify for Financial Assistance to Lower the Cost of Health Coverage

New federal financial assistance is now available through NY State of Health to higher-income individuals for the first time if they qualify. This financial assistance is being implemented as part of the American Rescue Plan Act (ARPA) signed into law on March 11, 2021.

Nearly 120,000 enrollees with income below 400 percent federal poverty level (FPL) are already receiving these enhanced tax credits and nearly 18,000 higher income enrollees are eligible for tax credits for the first time. Higher income individuals enrolled outside of NY State of Health and uninsured individuals may also be eligible for enhanced tax credits available through NY State of Health. Before the ARPA, tax credits were not available to higher income individuals (i.e., those earning more than $51,040 and families of four earning more than $104,800). Through the ARPA, higher-income individuals and families are now eligible for the federal tax credits. These federal tax credits are only available when individuals enroll in a health plan through NY State of Health.

Individuals with low or moderate incomes (i.e., those earning up to $51,040 and families of four earning up to $104,800) who were previously eligible for tax credits are now eligible for higher tax credits. NY State of Health automatically applied higher tax credits without enrollees needing to take any action. Enrollees can make changes to their account by logging into their NY State of Health account, contacting an Enrollment Assistor, and/or calling NY State of Health at (855) 355–5777.

To allow as many individuals as possible to access these enhanced tax credits, the 2021 Open Enrollment Period has been extended through December 31, 2021. Individuals and families can apply for coverage through the NY State of Health website, by phone at (855) 355‑5777, or by connecting with a free enrollment assistor via the NY State of Health Find a Broker/Navigator" search tool.

Additional Information

To read more about how NY State of Health enrollees benefit from the ARPA, providers can visit the How NY State of Health Enrollees Benefit from the American Rescue Plan web page.

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The eMedNY Provider Outreach and Training Tab

eMedNY encourages all providers to reference the "Provider Training" web page for useful billing resources, training information, contacts, and additional reference documents for provider billing needs. The page may be found from the eMedNY home page then select the "Provider Outreach and Training" tab.

"Provider Outreach and Training" Tab Options:

  • Training Calendar and Registration – Providers can view the schedule of upcoming webinars, all covering a variety of topics, such as New Provider/New Biller, ePACES, Eligibility, and more provider specific topics.
  • Training Videos – Providers that are unable to attend training sessions can conveniently access training videos to fit training into their schedule.
  • Contact Provider Outreach – Providers in need of further training can connect with an eMedNY Regional Representative for a more personalized training experience. Interested providers must complete a Contact Provider Outreach Form and an Outreach Representatives will respond to their requests.
  • Additional Resources – Providers can access links to ePACES Claim Quick Reference Guides (Professional Real Time, Professional, Dental and Institutional); ePACES Reference Sheets; Useful Tools, which include the Edit/Error Knowledge Base (EEKB) Search Tool, NYS Medicaid Pre-Adjudication Crosswalk for Health Care Claims document as well as eMedNY LISTSERV® sign-up information.
  • About Provider Outreach – Providers can learn more about the Provider Outreach team and how they can assist providers.

Questions and Additional Information

Providers with additional training needs should contact the eMedNY Call Center at (800) 343‑9000.

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Fluoride Varnish Application Expansion for Dental Providers

New York State (NYS) Medicaid reimburses for topical fluoride treatment when professionally administered in accordance with appropriate standards. This benefit is limited to gel, foam, and varnish. Effective July 1, 2021 for Medicaid fee-for-service (FFS) members and Medicaid Managed Care (MMC) enrollees [including Mainstream MMC Plans, as well as HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs)], Current Procedural Terminology (CPT) code "D1206" Topical application of Fluoride Varnish is reimbursable for members/enrollees between six months and 20 years of age (inclusive) up to four times per year. However, there must be an interval of not less than three months between any type of fluoride treatment to qualify for reimbursement. For members/enrollees 21 years of age and older, both "D1208" and "D1206" are only approvable for those members/enrollees identified with a Recipient Exception code of RE "81" (Traumatic Brain Injury Eligible) or RE "95" [Office of Persons With Developmental Disabilities (OPWDD) / Managed Care Exemption], or in cases where salivary gland function has been compromised as a result of surgery, radiation, or disease. Fluoride treatments that are not reimbursable include:

  • treatment that incorporates fluoride with prophylaxis paste,
  • topical application of fluoride to the prepared portion of a tooth prior to restoration,
  • fluoride rinse or "swish", and
  • treatment for desensitization.

Note: "D1208" Topical application of fluoride excluding varnish is reimbursable once per six-month period for members/enrollees between one and 20 years of age (inclusive). This expansion does not apply to non-dental practitioner application of fluoride varnish in a primary care setting using CPT code "99188".

Questions and Additional Information:

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NYS Medicaid Fee-for-Service Preferred Diabetic Supply Program, Revised

Effective July 22, 2021, the New York State (NYS) Medicaid fee-for-service (FFS) Preferred Diabetic Supply Program (PDSP) will follow updated criteria for the coverage of Continuous Glucose Monitors (CGM) and disposable insulin pumps to align with the policy update found in the article titled NYS Medicaid Coverage of Real-Time Continuous Glucose Monitors found in the April 2021 Medicaid Update. For a list of products available on the NYS Medicaid FFS PDSP providers can visit the PDSP list.

Coverage of CGM may be available for members who are diagnosed with type 1 diabetes and meet all of the following criteria:

  • the member is under the care of an endocrinologist, or an enrolled Medicaid provider with experience in diabetes treatment, who orders the device;
  • the member is currently performing multiple finger-stick glucose tests daily;
  • the member is on an insulin treatment plan that requires frequent adjustment of insulin dosing; and
  • (for real-time (RT) CGM only) the member is able or has a caregiver who is able to hear and view RT-CGM alerts and respond appropriately.

Coverage of disposable insulin pumps (i.e. Omnipod) may be available for members who are diagnosed with diabetes mellitus when ordered by an endocrinologist or a medical practitioner, who has experience managing patients on continuous subcutaneous insulin infusion therapy, if the following criteria are demonstrated and documented in the clinical record:

  • the member has a diagnosis of gestational diabetes; or
  • the member has been on a program of multiple daily injections of insulin (i.e., at least three injections per day) with frequent self-adjustments of their insulin dose for at least six months prior to initiation of the insulin pump and has failed to achieve acceptable control of blood sugars that are not explained by poor motivation or compliance; and
  • the member completed a comprehensive diabetes education program as meets one or more of the following criteria while receiving multiple daily injections:
    • HbA1c >seven percent
    • History of recurring hypoglycemia
    • Wide fluctuations in blood glucose before mealtime (>140mg/dl)
    • Dawn phenomenon in a fasting state (>200mg/dl)
    • History of severe glycemic excursions

If the member does not meet all criteria listed for the requested product, the provider must submit a prior authorization (PA) request to the Magellan Clinical Call Center by phone at (877) 309‑9493. Members currently using CGM, or a disposable insulin pump covered under the PDSP, will be allowed to continue use.

Additional Information and Questions:

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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