Transition (Carve-Out) of Pharmacy Benefit from Managed Care to Fee-For-Service (FFS)

All Stakeholder: Implementation Update

  • Presentation also available in Portable Document Format (PDF)
February 26, 2021


All Stakeholders: Monthly

NYS DOH will lead and provide all interest stakeholders with updates, facilitate a Q&A session, and incorporate feedback into the workplan as needed.


  • Monthly meetings ongoing starting with July 13 session
  • Remaining meetings scheduled for third Monday of each month

Technical Workgroup: Bi-weekly

NYS DOH is leading working sessions with Medicaid Managed Care Plans (and other subject matter experts as needed) to address transition topics and incorporate feedback into the workplan as needed.


  • Topics covered include Roles & Responsibilities, Scope of Benefits, Data Sharing, Transition Strategy, Member & Provider Communication, Value-Based Payments, QARR Measures, Program Integrity, DME Supplies, and Model Contract, Managed Care Inquiry Process, Physician-Dispensed Drugs, Non-Enrolled Providers
  • Will continue to focus on standing topics of data sharing, transition & communication activities, and provider enrollment and focus topic as needed

340B Advisory Group: Four Meetings

To provide non-binding recommendations by October 1, 2020 regarding the reimbursement of 340B claims.


  • 340B advisory group meetings held on 8/5, 8/26, 9/16.
  • The state is finalizing a methodology to distribute the > $100 Million funding directly to 340B providers and engaging with stakeholders for feedback.
Key Deliverables and Timeline Update
Deliverable(s) Target Date
Complete Work Plan and Establish State Transition Team and 340B Advisory Group June 2020 ✔️
Recurring Workgroup Calls with Health Plans and All Stakeholders begin July 2020 ✔️
Frequently Asked Questions Posted to the NYS DOH Website August 2020 ✔️
Finalize NYS DOH/Managed Care Plan Roles and Scope of Benefits September 2020 ✔️
Consensus between the state and plans on data sharing concept October 2020 ✔️
Deliver file formats, data dictionary, and process for daily claim file November 2020 ✔️
Transition Analysis Conducted (e.g., Formulary, DME, OTC Comparisons), Changes Made To Smooth Transition and Transition Strategy Finalized November 2020 ✔️
Identify Sections of the Model Contract that Require Changes December 2020 ✔️
Notice of 1115 Waiver Amendment December 2020 ✔️
Required System Changes Identified and Implemented December 2020 ✔️
340B Related State Plan Amendment (SPA) Submitted (if necessary) December 2020 ✔️
Initial Special Edition Medicaid Update Published December 2020 ✔️
Systems Stress Testing Performed January 2021 ✔️
Member and Provider Notifications Sent and Second Special Edition Medicaid Update Published February 2021
Customer Service Staff Hired and Trained February 2021
Make Required Changes to Common Benefit Identification Card (CBIC), Carrier or Notice March 2021
1115 Waiver Amendment and SPA Approved by CMS March 2021
Go Live: Daily Calls with Stakeholders (through 4/30/2021 or Beyond as Needed) By April 1, 2021

Implementation Date Update: Moved from 4/1/21 to 5/1/21
…stay tuned to LISTSERV for updates to website contents…

Transition & Communication Activities
Outreach Strategy Update

General Member Notice of Change

Notify members that their pharmacy benefits will shift from Managed Care Plans to NYS Medicaid Fee-for- Service and provide them with relevant information about the program (MCPs)

Non-Preferred Products
  1. Provide high-volume non-preferred product prescribers with general information regarding the Medicaid FFS preferred drug program (NYS)
  2. Provide targeted product-specific information to prescribers of non-preferred products so they can support patients in transitioning appropriate products (NYS)
Non-Enrolled Providers

Pharmacies, DMEPOS Suppliers, Prescribers*

  1. Provide targeted information to providers now serving managed care members who are not now enrolled in FFS of options to enroll or transition members (NYS and MCPs)
  2. Provide targeted notification to members with providers who have not enrolled in FFS so they can transition to new providers (MCPs)

*We will also conduct similar outreach following this approach for physician-dispensers of ineligible drugs

Restricted Recipients

Inform members that there are no changes to lengths of restrictions, and provide relevant plan and state contact information (MCPs)

Timeline Update

Updated Implementation Date: May 1, 2021
Implementation Strategy Notes
Pharmacy Enrollment Policy Changes
  • Bordering States May Enroll
  • Out of state (non-bordering) pharmacies serving 10 or more Medicaid Managed Care members in the year prior to 5/1/21 may enroll
  • Unmet Need
  • Provisional/Fast Track Enrollment Process
✓ 97% of Medicaid Managed Care Member are using Medicaid FFS pharmacies.
✓ 98% of Medicaid Managed Care prescriptions are filled by Medicaid FFS pharmacies.
  • Claims will continue to pay, after 5/1/21 for non-enrolled prescribers.
  • Prescribers should enroll if they want to want to continue to serve Medicaid members after 7/31/21.
  • Provisional/Fast Track Enrollment Process may be used for Physicians, Nurse Practitioners and Physician Assistants, but they will need to fully enroll at the end of the COVID-19 emergency.
✓ NYS DOH will monitor enrollment and send reminders to non enrolled prescribers.
Provisional Enrollment Portal
Provider Enrollment
DMEPOS Enrollment Policy Changes
  • Out of State brick and mortar locations if servicing members in the common NY marketing area
  • Manufacturer and out of state suppliers under limited circumstances
✓ Nearly all Medicaid Managed Care members are using Medicaid FFS DMEPOS providers.
Physician Dispensing
  • Policy aligns with Education Law
  • Information regarding how to sign up as a physician dispenser is forthcoming
✓ Very small number of Physician Dispensers (˜ 12 NPIs)

Data Sharing development and testing is on track including:

  • Prior authorization - data will allow FFS to honor managed care prior authorizations
  • Daily Claims File - data will provide the plans with data they need to support operations & care management
  • On-Demand Reporting - reports will provide the plans with specific-purpose data to support operations and care management

Website Updates


Information regarding the transition of the pharmacy benefit from Managed Care to FFS will be posted at the above website.

Email: – Please write Carve-Out in the subject line



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