Pharmacy Carve-Out: Transition & Communications Activities Timeline

  • Timeline also available in Portable Document Format (PDF)
Important:

The FY 2022 Enacted Budget delays the transition of the Medicaid pharmacy benefit by two years, until April 1, 2023. The below Transition & Communication Activities have been updated accordingly.
Updated May 18, 2021

The following charts provides additional context and information related to the New York State Department of Health´s (NYS DOH) transition and communication activities of the Pharmacy Carve-Out from Managed Care (MC) to Fee-For-Service (FFS), effective April 1, 2023.

Who What When Notes
NYS DOH Submit Report to MCOs related to Erectile/Sexual Dysfunction Drugs and Sex Offender Registry. By 9/30/2022 Last timeframe reported out will be Quarter 2 of Calendar Year (CY) 2022.
Managed Care Plans Audit - Non-Covered Products 10/1/2022 Plans should complete review/audit of non-covered products (e.g., non-rebate signers) and ensure they are not covered as of 10/1/2022, per the last data file provided by NYS DOH in Q3 of CY2022. The Department will continue to run data and provide updated files on a regular basis (minimum quarterly).
Managed Care Plans Submission of Prescriber Prevails Prior Authorization Activity to NYS DOH 10/20/2022 Includes Prior Authorizations through 9/30/2022.
NYS DOH Final review of plan submitted formulary files & feedback 11/24/2022  
Managed Care Plans Submit test files of approved Prior Authorizations (PA). 12/9/2022 Submit test files to NYS DOH in accordance with testing guidance shared with the Medicaid Managed Care Plans.
Managed Care Plans Submit Approved Prior Authorizations (PAs) to NYS DOH TBD PAs will be honored after the transition. a. Initial file submission b. 1 st "Catch-Up" File Submission c. 2 nd "Catch-Up" File Submission
NYS DOH Load Approved Clinical Medicaid Managed Care Prior Authorizations (PAs) TBD Prior Authorizations approved by Medicaid Managed Care plans will be honored after the transition. a. Initial File Submission b. 1 st "Catch-Up" File Submission c. 2 nd "Catch-Up" File Submission
Managed Care Plans Formulary file freeze 12/31/2022 No changes to be made for o n formulary/off- formulary statu s. Other maintenance such as adding new drugs, criteria changes due to FDA labeling changes would continue.
NYS DOH Formulary file freeze 12/31/2022 No changes to be made for preferred/non-preferred status. Other maintenance such as adding new drugs, criteria changes due to FDA labeling changes would continue.
Managed Care Plans Formulary file submission to NYS DOH 1/6/2023 Includes changes/updates as of as of 12/31/2022, in order to update the Medicaid Managed Care Pharmacy Benefit Information Center.
Managed Care Plans Confirm system readiness for claim denials 1/14/2023 Ensure Managed Care Plan systems are updated to deny pharmacy claims effective 4/1/2023 with standard NYS DOH approved messaging.
Managed Care Plans Pharmacy (NCPDP) Claim Encounter Submissions Ongoing, for service dates through 3/31/2023. Ensure that encounters are submitted daily, not more than 1 business day from the date of adjudication of the corresponding claim. In conformance with Plan's PBM agreement.
NYS DOH Outpatient Pharmacy Per Member Per Month (PMPM) Payments to plans End 3/31/2023, except for retroactive adjustments Plans may initiate retroactive adjustments when:
  • there was active enrollment prior to 4/1/23 that had not been previously billed for, or
  • a plan billed for a member prior to 4/1/23, for which there was not active enrollment. In this case, the plan would reverse the capitation claim in a subsequent period.
Managed Care Plans Member Material Changes By 4/1/2023 Make necessary changes to member materials and ID Cards.
NYS DOH Outpatient pharmacy inquiries received by the Plans Beginning 4/1/2023 NYS DOH has provided the process to refer inquires to NYS DOH, to the Managed Care Plans.
NYS DOH Collaborative DUR Continuing After 4/1/2023 Provide DUR information and other related reports that will assist plans with medication adherence and/or disease management programs.
NYS DOH Transition Period 4/1/2023 -6/30/2023 The Department has established a transition period of April 1, 2023 through June 30, 2023. This is to ensure that members can obtain medications through FFS, that had been previously covered by their Medicaid Managed Care Plan without going through prior authorization. During the transition period, members will be provided with a one-time, temporary fill for drugs that require prior authorization under the FFS program (e.g., non- preferred products).
NYS DOH Deliver daily claims test files to plans TBD Deliver test files to Medicaid Managed Care Plans in accordance with the Interface Control Document specifications (ICD). a. Form & Fit File b. Test File #1 c. Test File #2
NYS DOH Daily Claims File Beginning 4/2/2023 NYSDOH begins delivering daily claims files (including paid, denied and reversed) to the Managed Care Plans.
Managed Care Plans Pharmacy Benefit Manager Quarterly Report 4/30/2023 Submit quarterly Pharmacy Benefit Manager report. Note: This will be the last quarterly PBM report submitted by MCPs.
NYS DOH On-Demand Reports TBD NYSDOH begins delivering agreed on-demand reports to the Managed Care Plans.
Managed Care Plans Provider Network Data Set (PNDS) File Submission – Quarter 1 TBD Submit Quarter 1 PNDS data to NYS DOH including pharmacy network data. Note: Future PNDS data submissions (Quarter 2 and thereafter) to NYS DOH should exclude pharmacy network data.
Managed Care Plans Claims submission deadline Per Plan's agreement with their PBM The last day that Managed Care Plans will pay claims for service dates prior to 4/1/2023.
Managed Care Plans Physician Administered Claim Encounter Submissions N/A Physician administered drugs, when billed as an institutional or medical claim, will continue to be provided by the managed care plans and claim encounters will continue to be submitted to NYS DOH.
Managed Care Plans DUR Reports N/A DUR survey for 2023- Due 6/30/2023 . The reporting period is 10/1/2021 – 9/30/2022. DUR survey for 2024 - the reporting period is 10/1/2022- 9/30/2023 (Only member data through 3/31/2023 ). Physician administered drug information will continue to be required post carve-out.
Who What When Notes
NYS DOH Website Updates: 11/1/2022 -6/30/2023 Make relevant website updates such as:
  • Notification of carve-out (e.g., a banner)
  • How to find the Medicaid Client Identification Number (CIN) on the Managed Care Plan ID card.
  • Links to relevant Medicaid Update articles
NYS DOH Medicaid Update and Email Blast 11/14/2022 Initial Medicaid Update Article published.
NYS DOH Non-FFS-Enrolled Provider Communication TBD NYS DOH will send targeted communications regarding the need to enroll in Fee-For-Service (FFS) effective 4/1/2023 to non-enrolled providers (pharmacies, prescribers, and Durable Medical Equipment (DME)).
Managed Care Plans Non-FFS-Enrolled Provider Communication TBD Managed Care Plans will send targeted communications regarding the need to enroll in Fee-For- Service (FFS) effective 4/1/2023 to non-enrolled in-network and out-of- network providers (pharmacies, prescribers, and Durable Medical Equipment (DME)).
NYS DOH Plan Notice of Benefit Change By 1/31/2023 Pursuant to Section 4.3 of the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Model Contract, Modification of the Benefit Package Services, the Department of Health (Department) must provide Plans at least 60 days advance notice of modifications to the benefit package.
NYS DOH Medicaid Update 2/1/2023 Second Medicaid Update Article published.
Managed Care Plans Member Notice of Change 2/1/2023-2/28/2023 Mail Member Notice of Change per assigned mailing schedule provided by NYS DOH. The Member Notice of Change informs members of the change and that they can use their plan ID Card or their Medicaid Card to access pharmacy services
Managed Care Plans Website Updates 2/1/2023 – 3/31/2023 Make relevant website updates.
NYS DOH Update applicable system generated member notices. TBD Conduct appropriate updates to the system generated notices that provide a description of the pharmacy benefit.
  1. NYSOH Member Eligibility Notices for members who enroll in Medicaid via the NYSOH.
  2. Client Notice Subsystem Medicaid Acceptance Notices for members who enroll in Medicaid via their Local Department of Social Services (LDSS) For more information on where a member should enroll (NYSOH or LDSS) please review the FAQ "How do I apply for Medicaid?" within the General Medicaid FAQs section of the Medicaid in New York State website.
NYS DOH Custom provider notifications By 3/31/2023 Prescribers (high-volume) and pharmacies (Brand Less Than Generic) will be notified of their patients that are on non-preferred products.
Managed Care Plans Claims Denial Messaging Effective 4/1/2023 Implement claim denial messaging that notifies pharmacies to submit claims to the FFS program.