Pharmacy Carve-Out: Transition & Communication Activities

  • Timeline also available in Portable Document Format (PDF)

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, 2021.

Who What When Notes
Managed Care Plans Submission of Prescriber Prevails Prior Authorization Activity to NYS DOH ✔️
Includes Prior Authorizations through 6/30/2020.
NYS DOH Final review of plan submitted formulary files & feedback ✔️
Managed Care Plans Audit - Non-Covered Products ✔️
Plans should complete review/audit of non–covered products (e.g. non rebate signers) and ensure they are not covered as of 10/1/2020, per the last data file provided by NYS DOH on 7/31/2020. The Department will continue to run data and provide updated files on a regular basis (minimum quarterly).
Managed Care Plans Submit test files of approved Prior Authorizations (PA). 12/11/2020 Submit test files to NYS DOH in accordance with testing guidance shared with the Medicaid Managed Care Plans.
Managed Care Plans Formulary file freeze 12/31/2020 No changes to be made for on–formulary/off–formulary status. Other maintenance such as adding new drugs, criteria changes due to FDA labeling changes would continue.
NYS DOH Formulary file freeze 12/31/2020 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.
NYS DOH Submit Report to MCOs related to Erectile/Sexual Dysfunction Drugs and Sex Offender Registry. By 12/31/2020 Last timeframe reported out will be Quarter 2 of Calendar Year (CY) 2020.
Managed Care Plans Formulary file submission to NYS DOH 1/5/2021 Includes changes/updates as of as of 12/31/2020, in order to update the Medicaid Managed Care Pharmacy Benefit Information Center.
NYS DOH Deliver daily claims test files to plans By 1/8/2021 Deliver test files to Medicaid Managed Care Plans in accordance with the Interface Control Document specifications (ICD).
Managed Care Plans Submit Approved Prior Authorizations (PAs) to NYS DOH
  1. 1/22/2021
  2. 3/1/2021
  3. 4/3/2021
PAs will be honored after the transition.
  1. Initial file submission
  2. 1st "Catch–Up" File Submission
  3. 2nd "Catch–Up" File Submission
Managed Care Plans Confirm system readiness for claim denials 3/1/2021 Ensure Managed Care Plan systems are ready to deny pharmacy claims effective 4/1/2021.
Managed Care Plans Pharmacy (NCPDP) Claim Encounter Submissions Ongoing, for service dates through 3/31/2021. Ensure that encounters are submitted daily, not more than 1 business day from the date of adjudication of the corresponding claim.
NYS DOH Outpatient Pharmacy Per Member Per Month (PMPM) Payments to plans End 3/31/2021, except for retroactive adjustments Plans may initiate retroactive adjustments when:
  • there was active enrollment prior to 4/1/21 that had not been previously billed for, or
  • a plan billed for a member prior to 4/1/21, for which there was not active enrollment. In this case, the plan would reverse the capitation claim in a subsequent period.
NYS DOH Load Approved Medicaid Managed Care Prior Authorizations (PAs) TBD Prior Authorizations approved by Medicaid Managed Care Plans will be honored after the transition. 1 st File Loaded: TBD 2 nd "Catch Up" File Loaded: TBD
Managed Care Plans Member Material Changes By 4/1/2021 Make necessary changes to member materials and ID Cards.
NYS DOH Outpatient pharmacy inquiries received by the Plans Beginning 4/1/2021 NYS DOH to provide proposed process to the Managed Care Plans.
NYS DOH Collaborative DUR Continuing After 4/1/2021 Provide DUR information and other related reports that will assist plans with medication adherence and/or disease management programs.
NYS DOH Transition Period 4/1/2021 –6/30/2021 The Department has established a transition period of April 1, 2021 through June 30, 2021. 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 drugs).
NYS DOH On–Demand Reports TBD Begin provision of top priority on– demand reports.
NYS DOH Daily Claims File Beginning 4/2/2021 NYSDOH begins delivering daily claims files (including paid, denied and reversed) 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 4/1/2021.
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 2021– Due 7/1/2021 , unless CMS delays it for some reason. (It was delayed to 9/30/2020 this year because of COVID.) The reporting period is 10/1/2019 – 11/30/2020. DUR survey for 2022 – the reporting period is 10/1/2020– 11/30/2021 (So only member data through 3/31/2021 ). Physician administered drug information will continue to be required post carve–out.
Who What When Notes
NYS DOH Website Updates: 11/1/2020 –6/30/2021 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 ✔️
Informs pharmacies, prescribers and Durable Medical Equipment (DME) Providers that are not enrolled in Medicaid Fee-For- Service (FFS), of the need to enroll, to continue to serve Medicaid Managed Care members effective 4/1/2021.
NYS DOH Non–FFS–Enrolled Provider Communication 12/7/2020 – 4/1/2020 NYS DOH will send targeted communications regarding the need to enroll in Fee–For–Service (FFS) effective 4/1/2021 to non–enrolled providers (pharmacies, prescribers, and Durable Medical Equipment (DME)).
Managed Care Plans Non–FFS–Enrolled Provider Communication 12/7/2020 – 4/1/2020 Managed Care Plans will send targeted communications regarding the need to enroll in Fee–For– Service (FFS) effective 4/1/2021 to non–enrolled in–network and out–of– network providers (pharmacies, prescribers, and Durable Medical Equipment (DME)).
NYS DOH Medicaid Update 12/31/2020 Initial Medicaid Update Article published.
NYS DOH Medicaid Update 2/28/2021 Second Medicaid Update Article published.
NYS DOH Prescriber Outreach 2/1/2021–4/1/2021 Conduct prescriber outreach activities targeted to inform high volume prescribers of non–preferred products and actions that can be taken to smooth the transition (e.g. change to a preferred product or seek prior authorization).
NYS DOH CBIC Card Carrier Language Update Effective 2/1/2021 Update Client Benefit Identification Card (CBIC) card carrier language to include applicable information for the pharmacy carve–out.
NYS DOH Update NYSOH plan benefit summary information. No Changes Required Conduct appropriate updates to the NYSOH enrollment screens that provide a description of the pharmacy benefit.
Managed Care Plans Member Notice of Change 2/1/2021 – 2/28/2021 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 2/1/2021 – 3/31/2021 Make relevant website updates.
Managed Care Plans Claims Denial Messaging Effective 4/1/2021 Implement claim denial messaging that notifies pharmacies to submit claims to the FFS program.
NYS DOH Custom member and/or prescriber notifications 4/1/2021 – 6/30/2021 Prescribers and members will be notified of their patients that are on non–preferred drugs. Guidance will be provided to inform of the onetime transitional fill, alternative drugs, and the prior authorization process.