New York State Medicaid Update - October 2021 Volume 37 - Number 12

In this issue …

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New York State Medicaid Fee-for-Service Policy and Billing Guidance for Chimeric Antigen Receptor T-cell Therapy

Effective November 1, 2021, New York State (NYS) Medicaid fee-for-service (FFS) will continue to reimburse providers for chimeric antigen receptor (CAR) T-cell therapy; however, providers should begin billing for these medications in accordance with the New York State Medicaid Program Physician – Procedure Codes, Section 2- Medicine, Drugs and Drug Administration document.

This guidance will supersede the two existing policies listed below:


Any off-invoice discounts or rebates received from manufacturers must be remitted to Medicaid. Additionally, consistent with any performance guarantees conveyed by the manufacturers of CAR T-cell therapies (e.g., providers will only pay if patients go into remission), Medicaid may not be billed if no payments have been made by providers to the manufacturers. Storage and handling charges are included in APR-DRG inpatient payments and APG outpatient payments so they will not be reimbursed separately.

Medicaid Managed Care Billing

A provider participating in Medicaid Managed Care (MMC) should check with the patient health plan to determine the plan’s billing policies for CAR T-cell therapy. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program - Information for all Providers Managed Care Information document.

FFS Billing:

  • A provider can obtain the applicable Healthcare Common Procedure Code System (HCPCS) code for the CAR T-cell treatment using the Fee Schedule listed on the eMedNY "Free Standing or Hospital Based Ordered Ambulatory Manual" web page.
  • The associated National Drug Codes (NDCs) must be included on the claim.
  • For a CAR T-cell therapy that has not been assigned a HCPCS code, the appropriate "unclassified biologics" code of "J3590" must be used. The provider is to follow the "By Report" billing process. Instructions can be found in the eMedNY New York State Medicaid Program Ordered Ambulatory Procedure Codes document.
  • Payment will be made in addition to the inpatient All Patients Refined-Diagnosis Related Groups (APR-DRG) payment or, when administered on an outpatient basis, in addition to the outpatient Ambulatory Patient Group (APG) payment.
  • A hospital is to submit a separate ordered ambulatory claim for a CAR T-cell therapy. An ordered ambulatory claim should be submitted on paper (using eMedNY 150003 claim form) and should include the hospital actual acquisition cost by invoice.
  • The following documentation must be included with the claim:

Questions and Additional Information:

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Reminder: Billing Guidance for Reporting Alternate Level of Care

As a reminder, hospitals should not bill for an inpatient acute level of care status when a patient has been transferred to Alternate Level of Care (ALC) status.

New York Codes, Rules, and Regulations (NYCRR), Title 10, §86-1.15(h), defines ALC services as "those services provided by a hospital to a patient for whom it has been determined that inpatient hospital services are not medically necessary, but that post-hospital extended care services are medically necessary, consistent with utilization review standards, and are being provided by the hospital and are not otherwise available". Hospitals must properly report occurrence span code "75", with the date span the member was in ALC, on the acute care claim. eMedNY Inpatient Billing Guideline §2.3.3 requires that ALC claims be split-billed. Split-billing is defined in the guideline as the "submission of multiple date range claims that when compiled represent the period from Admit to Discharge". Hospitals should not bill for acute levels of care for days when patients are in an ALC setting.

For additional information regarding inpatient billing, providers may refer to the eMedNY New York State UB-04 Billing Guidelines - Inpatient Hospital Manual.

Questions and Additional Information:

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NY State of Health Enrollment Continues to Increase as More New Yorkers Sign Up for Low-Cost Coverage Thanks to the American Rescue Plan and Enhancements Made to the New York Essential Plan

NY State of Health, the state official health plan Marketplace, has released a status report, Health Insurance Coverage Update, on the implementation of both the American Rescue Plan Act (ARPA) and 2021 enhancements to the New York Essential Plan that increase the affordability and accessibility of Marketplace coverage. The Health Insurance Coverage Update - September 2021 shows that as of August 3, 2021 more than 6.3 million individuals—or one in three New Yorkers—are enrolled in health coverage through NY State of Health. Enrollment has increased across all Marketplace programs since April 2021 when the State began implementing these changes. An additional 2.3 million New Yorkers continue to access Medicaid coverage through local departments of social services.

The ARPA, which was signed into law on March 11, 2021, increased the amount of financial help available to consumers and extended tax credits to higher income New Yorkers for the first time. This financial help has significantly lowered the monthly premium cost of Qualified Health Plans available through NY State of Health. More than 40,000 New Yorkers have enrolled in health coverage with this new financial assistance since April 2021.

New Yorkers are also benefitting from several state actions that enhance Essential Plan coverage and ease access to public coverage. NY State of Health now offers all eligible New Yorkers Essential Plan coverage with no monthly premium, no annual deductible, as well as dental and vision coverage for all enrollees at no extra cost. The Essential Plan has always included comprehensive benefits, free preventive care, and low copayments. Additionally, New York has adopted all available federal options to ensure that New Yorkers can easily access critical comprehensive health coverage during the ongoing public health emergency (PHE). As detailed in the Health Insurance Coverage Update:

  • Between March 2020 and August 2021, an additional 1.4 million individuals enrolled in health coverage through NY State of Health.
  • More than 40,000 new consumers have enrolled in Qualified Health Plan coverage after the ARPA increased the available financial assistance in April 2021.
  • The average tax credit available to lower the cost of Qualified Health Plan coverage increased by $100 per month—from $326 per month to $430 per month—saving consumers, on average, over $1,200 per year.
  • One-third of Qualified Health Plan enrollees (or nearly 72,000 people) pay less than $100 per month for their premium.
  • There are a record 914,000 enrollees in the Essential Plan as of August 2021.
  • Since the June 2021 elimination of the Essential Plan monthly premium along with the newly increased benefits, overall program enrollment has increased by more than 21,000 individuals. Of these new enrollees, more than 9,000 would have previously been required to pay premiums.
  • Sixty-one percent of all NY State of Health enrollees are less than 35 years of age.

How to Refer Someone for Coverage Information:

Important: Enrollment for 2021 coverage through NY State of Health continues through the end of this year. Enrollment in 2022 Qualified Health Plans begins November 16, 2021.

New Yorkers who need health coverage can apply through:

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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 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 NYS DOH "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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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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Medicare Coinsurance and Deductible Only Coverage Reminder

When providing services to Medicaid recipients enrolled with Medicare Coinsurance and Deductible Only coverage, Medicaid will only consider reimbursement of patient responsibility amounts of Medicare coinsurance and/or deductible amounts.

Additionally, if Medicare did not approve the claims, or services are provided that are not statutorily covered by Medicare, then the secondary claims submitted to Medicaid will be denied for:

  • Edit 01027 (Medicaid Coverage code "09"-Medicare approved Amount Missing)
  • Claim Adjustment Reason Code "16",
  • Remark Code "MA04" on 835 Electronic Remittance Advice, or
  • Heath Care Claim Status Code "171" on a 277 Claim Status Response.

Identifying Recipients with Medicare Coinsurance and Deductible Only Coverage:

When verifying eligibility using the Medicaid Eligibility Verification System (MEVS), enter the generic Service Type Code "30" on requests, if the member has Medicare Coinsurance and Deductible Only coverage, the Health Insurance Portability and Accountability Act (HIPAA) response will return the message "MEDICARE COINSURANCE DEDUCTIBLE ONLY".

Additional Information

Further information about MEVS responses can be found in the eMedNY MEVS/Dispensing Validation System (DVS) Provider Manual.

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

Kathy Hochul
State of New York

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

Brett R. Friedman
Acting Medicaid Director
Office of Health Insurance Programs