New York State Medicaid Update - April 2022 Volume 38 - Number 4

In this issue …

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


Reminder: Some Drug Categories are Excluded from Coverage in Pharmacy and Medical Benefits

The New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) programs cover an extensive drug benefit providing access to medically necessary drugs. There are, however, certain drug/drug classes that are not covered by Medicaid for certain diagnoses due to federal or state rules, as outlined in both the Social Security Act §1927(d)(2), located on the Social Security Administration "Payment for Covered Outpatient Drugs" website and in the eMedNY New York State Medicaid Fee-for-Service Program Pharmacy Manual Policy Guidelines document. This article serves as a reminder of those exclusions for both the FFS and MMC program areas, which are as follows:

  • agents when used for the treatment of anorexia, weight loss or weight gain [additionally pursuant to New York Code, Rules and Regulations (NYCRR) Title 18 §505.3(g)(3)];
  • agents when used for the treatment of sexual dysfunction unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration (FDA) [additionally pursuant to New York Social Services Law §365-a(4)(f)]; and
  • agents when used for cosmetic use or hair growth (additionally pursuant to NYCRR Title 18 §505.2(l)(5)).

Questions and Additional Information:

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Reminder: Medicaid Requires Coordination of Benefits

New York State (NYS) Medicaid providers are required to bill applicable third parties that may be liable for a claim before billing NYS Medicaid, as Medicaid is always the payor of last resort and federal regulations require that all other available resources be used before Medicaid considers payment. The November 2021 issue of the Medicaid Update article titled Reminder to Providers: NYS Requires Coordination of Benefits directed providers to exhaust all existing benefits prior to billing the Medicaid program. If a Medicaid member has third-party insurance coverage, the benefits of that coverage must be fully used before billing the NYS Medicaid program. Providers should always ask a Medicaid member if they have other third-party coverage to ensure the proper coordination of benefits.

All claims submitted for members with Medicare and/or other third-party insurance must accurately reflect payments and denials received from other insurers to allow correct calculation of Medicaid reimbursement amounts. The Explanation of Benefits (EOB), along with other documentation supporting Medicare with third-party reimbursement amounts, must be kept, and then made available upon request for audit or inspection by the NYS Department of Health (DOH), the Office of the Medicaid Inspector General (OMIG), the Office of the State Comptroller (OSC), or other state or federal agencies responsible for audit functions.

Additionally, for any claims submitted to Medicaid with zero-fill reimbursement from Medicare or third-party insurers, providers must retain evidence that the claims were initially billed to Medicare and/or third-party insurers and then were denied before seeking reimbursement from Medicaid. The exception to this policy, in which providers may bill Medicaid directly without first receiving denials, is for items that are statutorily not covered by the Medicare program. Providers are responsible for retaining the statutory exemptions from Medicare for audit or inspection.

Please note: When submitting an EOB, or other member related data, providers must ensure they are only submitting data relevant to the Medicaid member. All other patient information must be redacted prior to submission. It is important to ensure that you are not submitting Personally Identifiable Information (PII) or Protected Health Information (PHI) of non-Medicaid members to Medicaid.

Questions and Additional Information:

  • Fee-for-service (FFS) claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • Specific medical pended claims questions should be directed to the Bureau of Medical Review Pended Claims Unit at (800) 342-3005 (Option 3).
  • Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to enrollees MMC Plan.
  • MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.

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Reminder: Non-Coverage Decision for Viscosupplementation of the Knee

Effective May 19, 2022, for New York State (NYS) Medicaid fee-for-service (FFS), and effective June 23, 2022, for Medicaid Managed Care (MMC), the Medicaid program will be implementing system enhancements to reinforce the coverage decision described in the following sources:

There will be no reimbursement provided by Medicaid when the Healthcare Common Procedure Code System (HCPCS) codes, provided in the table below, are used for the treatment of osteoarthritis of the knee:

HCPCS Code Code Description
J7318 Hyaluronan or derivative, Durolane, for intra-articular injection, 1 mg
J7320 Hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg
J7321 Hyaluronan or derivative, Hyalgan, or Supartz, or Visco-3 for intra-articular injection, per dose*
J7322 Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg
J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose*
J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg
J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose*
J7327 Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose
J7328 Hyaluronan or derivative, GelSyn-3, for intra-articular injection, 0.1 mg
J7329 Hyaluronan or derivative, TriVisc, for intra-articular injection, 1 mg
J7331 Hyaluronan or derivative, Synojoynt, for intra-articular injection, 1 mg
J7332 Hyaluronan or derivative, TriLURON, for intra-articular injection, 1 mg
J7333 Hyaluronan or derivative, Visco-3, for intra-articular injection, per dose

*Coverage will be available for compendia-supported uses.

Please note: Medicaid will only cover administration fees for covered services. Coverage will continue for viscosupplementation for compendia-supported uses. For additional guidance regarding viscosupplementation claim requirements, the viscosupplementation Clinical Criteria Worksheet can be found on the NYS Department of Health (DOH) "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance" web page.

Questions and Additional Information:

  • FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at PPNO@health.ny.gov.
  • MMC general coverage questions should be directed to the OHIP, Division of Health Plan Contracting and Oversight (DHPCO) by email at covques@health.ny.gov or by telephone at (518) 473-1134.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollees MMC Plan.
  • MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.

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New York State Medicaid Non-Invasive Prenatal Screening for Trisomy 21, 18, and 13 Policy

Effective July 1, 2022, New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans, HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs), as well as Health and Recovery Plans (HARPs)], coverage of non-invasive prenatal trisomy screening, a form of non-invasive prenatal screening (NIPS), using cell-free fetal deoxyribonucleic acid (DNA), will be expanded to include members of any age, beyond the former coverage of individuals who meet risk criteria and/or are 30 years of age or older. This coverage includes both singleton and twin pregnancies, but not higher multi-gestational pregnancies.

Please note: This guidance is an update to the article titled NYS Medicaid Now Covers Non-invasive Prenatal Testing for Trisomy 21, 18, and 13, published in the October 2014 issue of the Medicaid Update, and to the article titled New York State Medicaid Expansion of Non-Invasive Prenatal Trisomy Screening Policy, published in the August 2021 issue of the Medicaid Update.

Considerations

On April 19, 2022, the U.S. Food and Drug Administration (FDA) issued a warning of the risk of false results, inappropriate use, and inappropriate interpretation of results with non-invasive prenatal screening tests. Per their communication, "[t]he FDA recommends that patients and health care providers discuss the benefits and risks of all prenatal genetic testing, including NIPS tests, with a genetic counselor or other health care provider before considering such testing or making any decisions about their pregnancy."

Providers can refer to the FDA "Genetic Non-Invasive Prenatal Screening Tests May Have False Results: FDA Safety Communication" web page, for a full-list of recommendations for patients and providers.

Reminders:

  • Genetic counseling is covered by Medicaid and should be provided to pregnant members prior to non-invasive prenatal testing to weigh benefits versus risks. Genetic counseling must also be provided to those who test positive for a fetal chromosomal abnormality.
  • Prenatal testing of a fetus by amniocentesis or chorionic villus sampling will continue to be covered:
    • subsequent to a positive or high-risk score on a NIPS test; or
    • subsequent to an inconclusive test result in a high-risk pregnancy.
  • Diagnostic testing (e.g., cytogenetic analysis or molecular genetic testing) for suspected aneuploidies continues to be covered if medically necessary.
  • Cell-free fetal DNA testing should not be offered to members who are pregnant with three or more fetuses because it has not been sufficiently evaluated in these groups.
  • Micro-deletion testing, in conjunction with non-invasive trisomy testing, is not reimbursable.

Questions and Additional Information:

  • Consistent with existing policy, NYS Regulations at 18 New York Codes, Rules and Regulations (NYCRR) §505.7(g)(4) requires providers to order tests, individually. No payment will be made for tests ordered as groupings or combinations of tests. For more information and for additional regulations pertaining to laboratory services, providers should visit the NYCRR "Title: Section 505.7 - Laboratory Services" web page.
  • FFS billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and Management (DPDM), by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to enrollee MMC Plans.
  • MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.

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Medicaid Consumer Fact Sheets Now Available

Medicaid consumer fact sheets, focused on prevention, treatment, and management of health conditions, as well as relevant Medicaid benefits that can be used to help members stay healthy, are available on the New York State (NYS) Department of Health (DOH) "MRT II Policies and Guidance" web page. Topics include asthma control, chronic kidney disease, Coronavirus Disease 2019 (COVID-19), diabetes, high blood pressure, HIV-PrEP (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), periodontal disease, sickle cell disease, smoking cessation, and tooth decay. Fact sheets are available in English, Spanish, Chinese, Russian, Haitian Creole, Bengali, Korean, Polish, Yiddish, Arabic and Italian. The most recently added fact sheet provides COVID-19 vaccination, testing, and treatment information and is currently only available in English. This fact sheet will be available in additional languages in the near future.

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Newborn Screening Amendment Requires Action from Hospitals and Providers Treating Newborns and Infants

Newborn screening is mandated in New York State (NYS) Public Health Law §2500-a and §2500-f. In 2022, the statute was amended to add glucose-6-phosphate dehydrogenase (G6PD) deficiency to the list of newborn screening conditions in NYS. G6PD deficiency was not added to the panel of conditions screened by the Newborn Screening Program through testing of dried blood spots; instead, the law, effective June 20, 2022, requires newborns be given a diagnostic test for G6PD deficiency if they:

  • present with hemolytic anemia; or
  • present with hemolytic jaundice; or
  • present with early onset increasing neonatal jaundice persisting beyond the first week of life (bilirubin level greater than the 40th percentile for age in hours); or
  • are admitted to the hospital for jaundice following discharge; or
  • have a familial, racial, or ethnic risk of G6PD deficiency (African, Asian, Mediterranean, or Middle Eastern ancestry).

Newborns and infants, who meet any one of the above criteria, must be tested for G6PD deficiency using a quantitative test.

Hospital and Provider Requirements

Hospitals and providers caring for newborns and infants should put systems in place to ensure that infants meeting any of the above criteria be administered a quantitative test for G6PD deficiency.

Questions and Additional Information:

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Ambulette Providers (Category of Service 0602) Performing Medicaid Transports at the Taxi/Livery Level in Sedans and Minivans

The purpose of this update is to align existing New York State (NYS) Medicaid Transportation policy with NYS Department of Transportation (DOT) policy. The NYS Department of Health (DOH) recognizes that some ambulette providers added sedans and minivans to their fleets to transport ambulatory patients in need of curb-to-curb transportation billable to Medicaid under livery procedure codes. NYS DOH has become aware that DOT will no longer inspect these sedans and minivans. Consistent with current practices of the DOT, only Medicaid transports performed by ambulette providers in ambulette vehicles, must be performed in vehicles inspected semi-annually by the DOT and by drivers certified under Article 19A of Vehicle and Traffic Law. Accordingly, ambulette providers may continue to use sedans and minivans to provide livery transports transports and such vehicles are not subject to DOT inspections.

Questions

Questions should be directed to the NYS DOH Medical Transportation Unit by telephone at (518) 473-2160 or by email at MedTrans@health.ny.gov.

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Medicaid Enrollment Requirements and Compliance Deadlines for Managed Care Providers

As previously stated in the January 2018 issue of the Medicaid Update article titled Medicaid Managed Care and Children's Health Insurance Program Network Providers Must Enroll in the New York State Medicaid Program, §5005(b)(2) of the 21st Century Cures Act and 42 CFR §438.602 require all Medicaid Managed Care (MMC) network furnishing, ordering, prescribing, referring and attending (OPRA) providers to be enrolled with the New York State (NYS) Medicaid program. Additionally, in accordance with 42 CFR §438.206(b)(4), MMC Plans will limit out-of-network services to services unable to be provided by network providers.

Out-of-Network and Non-Enrolled Providers

Effective September 1, 2022, MMC Plans will deny services from non-enrolled Medicaid or OPRA providers servicing more than ten members in the last 180 days. Out-of-network and non-enrolled MMC furnishing providers must enroll in Medicaid as a billing provider to continue receiving payment for services provided to an MMC member. NYS has adopted a process that will notify out-of-network providers to enroll in Medicaid. Out-of-network and non-enrolled Medicaid furnishing and OPRA providers servicing more than one MMC member are encouraged, without delay, to enroll now.

Enrollment of Physicians, Nurse Practitioners, Physician Assistants, Podiatrists, Dentists, Optometrists, Audiologists, and Certified Nurse Midwives:

Pharmacy Enrollment

Effective September 1, 2022, MMC Plans will deny payment to pharmacies that are not enrolled as a fee-for-service (FFS) Medicaid Type provider. Pharmacies are furnishing providers that must enroll in the NYS Medicaid program to continue receiving payment. Information on how to enroll is available on the eMedNY "Pharmacy Provider Enrollment" web page.

Criteria for NYS Medicaid Enrollment

Not all practitioner and pharmacy providers will meet criteria to qualify for enrollment. Providers can review the provider manuals available on the eMedNY "Provider Manuals" web page and on the eMedNY "Provider Enrollment and Maintenance" web page by selecting the appropriate provider type from the right-hand box titled "Provider List Filter".

How to Check Provider Enrollment Status

Providers can check their enrollment status by utilizing the tools available on the NYS DOH "Medicaid Enrolled Provider Lookup" web page. Search by entering your Medicaid Provider ID or your National Provider Identifier (NPI). Use the table below to determine your current enrollment status and the corresponding action necessary as required from the "Medicaid Type" provided in the result.

Providers who have submitted enrollment applications may check the status of their application in the Medicaid Pending Provider Listing file, updated weekly on the eMedNY "Medicaid Managed Care Network Provider Enrollment" web page.

Provider Type "Medicaid Type" Enrollment Status Action Required
Pharmacy FFS Enrolled (Qualified Billing Provider) No action*
MCO Not Enrolled (MCO Credentialed as a non-billing Provider) Enroll with Medicaid as a billing provider*
No result Not enrolled Enroll with Medicaid as a billing provider*
Practitioner/Prescriber FFS Enrolled (Qualified Billing Provider) No action**
MCO Not Enrolled (MCO Credentialed as a non-billing Provider) Enroll with Medicaid as a billing or an OPRA provider**
OPRA Enrolled (Qualified non-billing Provider) No action
No result Not Enrolled Enroll with Medicaid as billing provider** or if eligible as a OPRA provider

*Pharmacy providers not enrolled in Medicare must also enroll in Medicare as a participating provider.
**Some billing practitioners do not require Medicare enrollment, see enrollment index for your profession for more information.

Questions and Additional Information:

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

Kathy Hochul
Governor
State of New York

Mary T. Bassett, M.D., M.P.H.
Commissioner
New York State Department of Health

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