DOH Medicaid Update July 2001 Vol.16, No.7

Office of Medicaid Management
DOH Medicaid Update
July 2001 Vol.16, No.7

State of New York
George E. Pataki, Governor

Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.
Commissioner

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management,
14th Floor, Room 1466,
Corning Tower, Albany,
New York 12237



Change Will Result In Efficiency...The New EMEDNY
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Last year, Computer Sciences Corporation (CSC), the State's Medicaid fiscal agent, was awarded a contract from the New York State Department of Health (DOH) to replace and modernize the computer systems currently operated by eFunds and CSC. This new contract is referred to as eMedNY

During the Fall of 2001, CSC will replace the current Electronic Medicaid Eligibility Verification System (EMEVS) and assume responsibility for administration of the EMEVS. To ensure that the transition to CSC is smooth and efficient, changes to established procedures will be minimal. The new eMedNY eligibility system will be accessed and used in virtually the same way as the existing EMEVS system. The current telephone numbers used to access EMEVS services will not change.We will be contacting providers directly to train them on these minimal changes as necessary.

After this initial transition, a number of eMedNY changes will be implemented to enhance services to providers. As implementation progresses, providers will have enhanced processing efficiencies and access to information. We anticipate these changes will be beneficial to providers, and our goal is to provide a smooth transition. Details relating to upcoming changes will be presented in future issues of the Medicaid Update.

When fully implemented in 2003, eMedNY will offer enhanced features to improve provider interaction with the Medicaid program such as an eMedNYwebsite for online access to provider manuals and access to electronic remittances.

If you have any questions related to this article or the eMedNY Project, please telephone Patrick McGuinness at (518) 257-4461.


SMOKELESS TOBACCO-DIP, CHEW, SNUFF
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Dip, Chew and Snuff are all terms used for smokeless tobacco. A growing number of teens are using smokeless tobacco as an alternative to cigarettes. Smokeless tobacco products are just as addictive as cigarettes and are associated with serious health concerns.

SMOKELESS TOBACCO IS NOT A SAFE ALTERNATIVE TO SMOKING!

Chewing tobacco is a shredded tobacco that is placed between the cheek and teeth and is chewed or sucked. It is usually mixed with molasses and sugar and packaged in a pouch.

Snuff is a finely ground tobacco and is "dipped" by placing a pinch between the lip or cheeks and gums. It can be flavored with mint, wintergreen and other flavorings. It is usually packaged in a small round can.

Smokeless Tobacco-The Contents You Don't See

  • Nitrosamines-powerful cancer-causing agents. While only 5 ppb (parts per billion) are allowed in consumer products such as beer or bacon, spit tobacco contains from 20 to 43,000 times more nitrosamines.
  • Polonium 210-radioactive particles that turn into cancer-causing radon
  • Formaldehyde-embalming fluid
  • Cadmium-a metallic element; its salts are poisonous
  • Cyanide
  • Lead
  • Arsenic

Dental and Medical Professionals-What You Can Do

All health providers should advise against tobacco use in any form. Dental health clinicians, in particular, have a unique opportunity to provide brief advice to patients to quit using smokeless tobacco products. These brief interventions can increase abstinence rates significantly.

  • Ask about smokeless tobacco use when screening patients for tobacco use.
  • Advise your patients that smokeless tobacco is not a safe alternative to smoking
  • Warn patients, especially adolescents, of the dangers of smokeless tobacco use:
    • Oral Cancer
    • Tooth Decay
    • Addiction to Nicotine
    • Gum Recession
    • Cardiovascular disease
  • Assist in a quit plan, if needed.
  • Congratulate patients who have abstained from tobacco products including smokeless products.

Reminder: NYS Medicaid covers both prescription and non-prescription smoking cessation agents. For more information on Medicaid's smoking cessation coverage policy, or if you have questions related to this article, contact the Bureau of Program Guidance at (518) 474-9219.


ISSUES IN CARING FOR PEOPLE WITH ASTHMA
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Doctor

According to the American Academy of Allergy, Asthma and Immunology, asthma patients continue to experience poorly controlled asthma despite available effective therapies and nationally developed guidelines for diagnosis and management.

Three primary reasons have been found for failures in asthma treatment:

  • Failure of providers to follow asthma treatment guidelines;
  • Insufficient patient education, so that patients often do not understand what to do; and
  • Failure of patients to adhere to prescribed treatment regimens.

Cynthia Rand, Ph.D., of Johns Hopkins Asthma and Allergy Center in Baltimore, Maryland, conducted a study to determine factors that affect physician's acceptance and implementation of clinical guidelines and outlined a number of strategies to improve physician compliance with the guidelines including:

  • Certified Medical Education (CME) programs
  • academic detailing
  • audit and feedback of individual behavior
  • continual reminders, both electronic and paper, to physicians on guideline content

Dr. Rand also studied the lack of patient adherence to therapeutic regimens and determined that adherence can not be predicted by level of education, income, disease severity, personality, age or gender. Dr. Rand concluded that to assure patient adherence to treatment regimens it is essential that the physician communicate well with the patient and individualize care. The physician needs to be cognizant of the patient's concerns, goals and ability to follow the prescribed regimen.

Source: Lazarus, Stephen, MD. "Improving Care for People with Asthma".
As published on Medscape March, 2001.

The NYS Medicaid program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of asthma. We encourage readers to share these publications with their clinical practitioners.

If you have questions related to this article, or suggestions on articles that would be of interest to you in improving health outcomes for your patients, please contact the Bureau of Program Guidance at (518) 474-9219.


THE EXPANDING WAISTLINE, OBESITY AND DIABETES
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Man

The Centers for Disease Control and Prevention (CDC) reported that diabetes in the United States rose approximately 6% in 1999, in what the Center called "dramatic evidence of an unfolding epidemic." The rise is blamed largely on obesity, which has increased an astonishing 57% from 1991.

The CDC reported a significant rise in obesity in the 1990's, resulting in more than half of the nation's adults being considered overweight. Obesity is defined as an excess of at least 20 pounds in an average person, but varies based on height. Experts have blamed America's "couch-potato" culture for the obesity that leads to diabetes Computer-centered lifestyles, easy fast food and disappearing space for outdoor exercise have all been cited. Obesity is no longer just a cosmetic issue, but a risk factor for serious illness. It is essential that Americans change their behaviors to reverse this dramatic trend. The current American lifestyle of inactivity and poor nutrition will ultimately increase the need for diabetes care in the future.

According to the American Medical Association, health care providers should stress the following:

  • Eat a healthy, balanced diet including fruits, vegetables, and whole grains - a diet with less than 30% of calories from fat.
  • Exercise regularly - researchers at the Harvard School of Public Health found that both moderately intense activities such as walking and vigorous activities such as running can substantially reduce the risk of type 2 diabetes.

We encourage readers to share the Medicaid Updates with their clinical practitioners. If you have questions related to this article, or suggestions on articles that would be of interest to you in improving health outcomes for your patients, please contact the Bureau of Program Guidance at (518) 474-9219


FAMILY HEALTH PLUS...COVERING THE UNINSURED
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On May 31, 2001 Governor Pataki and U.S. Secretary of Health and Human Services Tommy Thompson announced that New York had received federal approval of the necessary Medicaid waivers to implement Family Health Plus (FHPlus).

FHPlus is an expansion of Medicaid coverage for lower income adults (aged 19 -64) who do not have health insurance but have income or resources which disqualify them for other public health insurance programs. FHPlus builds upon the Child Health Plus model by providing a comprehensive set of benefits through managed care plans. Unlike Medicaid, there are no asset or resource tests. Parents with income up to 133% FPL($23,475 for a household of four)are eligible. FHPlus also covers uninsured adults without children whose income is at or below 100% of FPL ($8,590 for a single adult).

Application assistance will be available at a number of locations starting September 1, 2001 and coverage will begin as early as October 1, 2001. For more information on the program, individuals may call the FHPlus toll-free number at 1-877-934-7587 or visit our website:


AVOID BILLING ERRORS: MEDICAID'S PREPAID MENTAL HEALTH PLANS
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WHAT IS A PREPAID MENTAL HEALTH PLAN?

Since April 1, 1996 certain Medicaid recipients being served by mental health programs operated by the New York State (NYS) Office of Mental Health (OMH) have had the option of being enrolled in partially capitated managed care plans, known as Prepaid Mental Health Plans (PMHPs). These plans were designed to allow enrollees greater flexibility to access the specific types of psychiatric care that most appropriately meet their individual needs. Currently, there are 18 PMHPs operating throughout NYS. (The chart on pages 6 & 7 lists the Insurance Plan Code, plan name and contact numbers for each of these plans.)

WHAT IS COVERED BY A PREPAID MENTAL HEALTH PLAN?

The only services currently covered by PMHPs are three specific outpatient psychiatric services:

  1. mental health clinic
  2. continuing day treatment (CDT); or,
  3. intensive psychiatric rehabilitative treatment (IPRT).

If you are a provider of one of these three psychiatric services, you should refer a PMHP enrollee to their plan for these services.

WHAT IS NOT COVERED BY A PREPAID MENTAL HEALTH PLAN?

All other Medicaid covered services provided to a PMHP enrollee (e.g. dental, laboratory, radiology, physician, medical clinic, inpatient hospital, emergency room, etc.)are not covered by the plan and should be billed in the same manner as if the patient were not in a managed care plan.

PMHP authorization is not required in order for any of these other Medicaid services to be provided.

HOW DO I DETERMINE WHETHER MY PATIENT IS COVERED BY A PREPAID MENTAL HEALTH PLAN?

All providers are required to check the Electronic Medicaid Eligibility Verification System (EMEVS) prior to rendering services to:

  • determine a recipient's Medicaid eligibility; and,
  • understand the conditions of Medicaid coverage.

PMHP enrollees can be identified through EMEVS in the following way:

  • Recipient's Medicaid Coverage will show as "Eligible PCP";
  • Insurance Code will be one of the codes shown in the chart below; and,
  • Coverage Code will be "Q" which represents "psychiatric services only."

For example, for a person enrolled in the Creedmoor PMHP, the Insurance and Coverage Codes will appear as "JQ Q",where JQ is the Insurance Plan Code for the Creedmore PMHP, and Q is the Coverage Code.

If at any time you are not sure whether to provide a service, contact your patient's PMHP (see chart below).If you are unable to reach the plan contact, call NYS OMH's Customer Relations at 1-800-597-8471.

SPECIAL INSTRUCTIONS WHEN BILLING FOR SERVICES RENDERED

PMHPs are Medicaid managed care plans. PMHPs are not commercial health insurance plans.

Therefore, the PMHP coverage code should not be entered in the "Other Insurance" field on the claim form.

The "Other Insurance" field should be completed only if the recipient is covered by a commercial health insurance plan. In this situation, the coverage code of the other insurance plan should be entered.

SPECIAL INSTRUCTIONS FOR INPATIENT PSYCHIATRIC PROVIDERS

Inpatient psychiatric services are no longer covered under the PMHP.

If you are a non-state operated inpatient provider for psychiatric care, and you admit a PMHP enrollee, you should alert the PMHP to the admission and coordinate the medical care of your patient.

If you have any questions about this article, please contact Kate Cahill at (518)474-5050.

 

NEW YORK STATE OFFICE OF MENTAL HEALTH PREPAID MENTAL HEALTH PLANS (PMHPS)

Ins CdPlan NamePlan ContactContact Phone*Contact Fax
JD Middletown Prepaid Mental Health Plan Sherry Cole (845) 342-5511 x3650 (845) 342-4975
JE Mohawk Valley Prepaid Mental Health Plan Marie McCarthy (315) 738-4426(315) 738-4040
JFNew York Psychiatric Institute Prepaid Mental Health Plan Richard Herman (212) 543-5412 (212) 543-5962
JGPilgrim Prepaid Mental Health PlanLori Shore(631) 761-2408(631)761-4518
JHRochester Prepaid Mental Health PlanJeff Weyrauch(716) 242-1390(716) 241-1940
JIRockland Prepaid Mental Health PlanSondra Mauro(845) 359-1000 x2235(845) 359-1744
JJSt.Lawrence Prepaid Mental Health Plan James Spooner(315) 393-3000 x3529(315) 393-2670
JKSouth Beach Prepaid Mental Health PlanBill Henri(718) 667-2823(718) 667-2344
JLBinghamton Prepaid Mental Health PlanJohn Burke(607) 797-0680(607) 797-4315
JMBronx Prepaid Mental Health PlanJames Wagner(718) 931-0600 x3279(718) 597-8015
JNBuffalo Prepaid Mental Health PlanThomas Dodson(716) 816-2356 x2009(716) 885-0710
JOCapital District Prepaid Mental Health PlanJohn A. Freeman(518) 447-9611 x6971(518) 663-4987
JQCreedmoor Prepaid Mental Health PlanWilliam Fisher(718) 264-3603(718) 264-3635
JRElmira Prepaid Mental Health Plan Frederick Manzella(607) 737-4741(607) 737-9080
JSHudson River Prepaid Mental Health PlanJames Regan(845)483-4300 x7293 (845) 437-5160
JTHutchings Prepaid Mental Health PlanGlen Johnson(315) 473-4980 x4087(315) 473-4984
JVKingsboro Prepaid Mental Health PlanFlora Woods(718) 221-7480(718) 221-7120
JWManhattan Prepaid Mental Health PlanRebecca Costa(212) 961-8700(212)961-4394

*If no answer at PMHP contact phone number, call OMH Customer Service at (800) 597-8471.


ENTERAL THERAPY: BILLING AND COVERAGE
Pharmacists and Durable Medical Equipment Dealers
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SPECIALTY ENTERAL FORMULAS

  • Medicaid Billing Codes B4154 and B4155 represent enteral formulas that address special metabolic needs or modular components.
  • Before dispensing any enteral formula, an Electronic Medicaid Eligibility Verification System (EMEVS) Dispensing Validation System (DVS) authorization number must be obtained for the number of caloric units requested. (The number of calories per can, divided by 100, equals the number of caloric units per can.)
  • Reimbursement is limited to the lower of:
    • the acquisition cost plus 50% (by invoice to the provider); or,
    • the usual and customary charge to the general public
  • The prices indicated are:
    • Code B4154, $0.85 per caloric unit
    • Code B4155, $2.30 per caloric unit
  • When billing for codes B4154 and B4155, providers may either:
    • Charge up to the price indicated; or,
    • When the charge is greater than the price indicated, use "By Report" (BR) rules. (When billing BR, use a paper claim and include appropriate documentation (e.g., itemized invoice) indicating the total cost of the item, and any other factors that may be pertinent.) When submitting a claim with an invoice, providers are encouraged to write "INVOICE ATTACHED" in the description field on the claim form.
  • The provider must determine the billing method at the time the DVS authorization is obtained. The DVS authorization number and the number of caloric units for which authorization was obtained must be recorded on all claims. Prior approvals will not be granted for the purpose of correcting a provider's billing error.

INFANT FORMULAS

  • Standard milk-based infant formulas are not reimbursable by Medicaid.
  • Non-standard infant formulas are reimbursable by Medicaid under the appropriate enteral therapy code.
  • Recipients may contact their local Woman, Infant and Children (WIC) office for information on coverage of specific infant formulas covered under WIC.
  • Providers should confirm the availability of WIC coverage prior to billing Medicaid.

PRESCRIBERS

  • Enteral nutritional therapy is covered for nasogastric, jejunostomy or gastrostomy tube feeding or as a liquid oral nutritional therapy when there is a documented diagnostic condition where caloric and dietary nutrients from food cannot be absorbed or metabolized.
  • Medical necessity for enteral nutritional therapy must be substantiated by documented physical findings and/or laboratory data. The therapy must be an integral component of a documented medical treatment plan and ordered in writing by an authorized prescriber.
  • It is the responsibility of the prescriber to maintain documentation in the recipient's record regarding the medical necessity for enteral nutritional therapy.(For detailed standards, see pages 2-53 through 2-55 of the MMIS Durable Medical Equipment Provider Manual {Rev. 4/99}.)

If you have questions related to this article, please contact the Bureau of Medical Review and Payment at (518) 474-8161.


PHYSICIANS, WE NEED YOUR HELP!
MANDATORY BLOOD LEAD SCREENING FOR CHILDREN
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Childhood lead poisoning continues to be one of the most prevalent health concerns for young children in New York State. Due to the age of New York housing, the percentage of that housing in deteriorated condition, and the risk of exposure from home repairs and renovations, over 10,000 children are identified annually with harmful lead levels.

The Department of Health and Human Services' Centers for Medicare and MedicaidServicess (CMS), (formerly known as the Health Care Financing Administration ) requires all children enrolled in Medicaid to be tested at one and two years of age. Testing between 36 and 72 months of age is required if a child was not tested previously.

Similarly, the New York State Department of Health requires health care providers to test all children at ages one and two and at other ages based upon a risk assessment.

Venous blood is the preferred specimen for blood lead testing. Capillary blood may be used with appropriate collection procedures, in order to minimize contamination of the specimen with lead from dust on the skin.

The Erythrocyte Protoporphyrin (EP) test is no longer acceptable for lead screening as a significant number of children with elevated blood levels by current standards will have normal EP results.

Providers are to treat children in accordance to Center for Disease Control (CDC) guidelines covering patient management and treatment, including follow up blood tests and initiating an on-site investigation to determine the source of lead.

If you have any questions regarding this article, please contact Judith Lenihan at(518) 473-6020.


WE MADE AN ERROR...
YOU NEED TO CORRECT YOUR PROVIDER MANUAL
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Recently, the following providers were mailed a new policy section (dated 7/1/01) of your Medicaid Management Information System (MMIS) Provider Manual: Clinical Psychology, Clinical Social Worker, Free Standing Ordered Ambulatory, Hospital-based Ordered Ambulatory, Nurse Practitioner, Nursing Services, Ophthalmic, Physician and Podiatry.

There are two errors on Page 2-38a of the 7/1/01 revision of the policy section.

Under the heading, "The following recipients are exempt from all Medicaid co-payments:," the corrections should read as follows:

  • Recipients enrolled in managed care programs are exempt for all services
  • Recipients living in an OMRDD or OMH certified Community Residences are exempt;

Under the heading, "Additionally, the following co-payment exemptions apply to only specific types of providers:," the following should be added:

  • Tuberculosis Directly Observed Therapy
  • Psychotropic and tuberculosis drugs

MEDICAID CO-PAYMENT POLICY
A Review of Policy and Procedure
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Medicaid co-payments have been in effect since November 1993. This article reiterates co-payment policy. Please share this information with your staff and/or employees and with patients and/or customers when they have questions about Medicaid co-payments.The Department of Health Co-Payment Hotline at 1 (800) 541-2831 is available for questions Monday through Friday between 8:30 am and 5:00 pm.

  • Health care providers have an obligation to provide services and goods regardless of a recipient's ability to pay co-payments. The legislation enacting co-payments provides that a provider may not deny services to an eligible recipient based on a recipient's (or his/her agent's) statement that he/she cannot afford the co-payment. You may not refuse to provide services to otherwise eligible recipients who cannot afford to pay the co-payment. To refuse to provide services is an unacceptable practice.
  • You may:
    • request the co-payment each time a recipient needs services or goods;
    • ask a recipient for outstanding co-payments the next time he/she comes in;
    • send the recipient bills; or,
    • use other legal means to collect the co-pay due.
  • You must not reduce the amount charged on a Medicaid claim by the co-payment that is collected from a Medicaid recipient. Each claim that requires a co-payment will have the co-payment automatically deducted from the final payment when the claim is approved for payment.
  • Some recipients become eligible for Medicaid by spending part of their monthly income on medical care. Since co-payments paid or incurred can be used toward satisfying the spenddown (overage) in the following month, itemized bills or receipts for co-payments should be provided to recipients when requested.
  • When eligibility is verified and a service authorization, if appropriate, is obtained on the date of service through the Electronic Medicaid Eligibility Verification System (EMEVS), you are required to enter co-payment information for each recipient, regardless of whether recipients pay or do not pay the co-payment.There is a $100 maximum per recipient for all co-payments incurred per year. Entering co-payment information will help to ensure that EMEVS accurately indicates when co-payments are no longer due from recipients and should not be deducted from your claims for the remainder of the current co-payment year. The co-payment year starts April 1st and ends March 31st.
  • When a recipient reaches the $100 annual co-pay maximum, EMEVS will tell you that no co-payment is due from the recipient. The computer will automatically send the recipient a letter confirming the date on which the co-pay maximum was met and exempting the recipient from a co-payment until the end of the current co-payment year.
  • For help with entering co-payment data on EMEVS, please call the EMEVS Helpline at 1-800-343-9000. To order an EMEVS Provider Manual, contact Computer Sciences Corporation, our fiscal agent, at one of the following telephone numbers:

Professional Services   (800) 522-5535   (518) 447-9830
Practitioner Services   (800) 522-5518   (518) 447-9860
Institutional Services   (800) 522-1892   (518) 447-9810

  • You should become familiar with what services or items have a co-payment or are exempt from co-payments and what groups of recipients are exempt from co-payments. Please see the following two (2) tables.
  • If you have questions or concerns about Medicaid's co-payment policy, contact the DOH Co-Payment Hotline at toll-free 1-800-541-2831 for assistance.

 

TABLE OF MEDICAID CO-PAYMENTS & EXEMPT SERVICES

SERVICE OR ITEM AMT DETAILS ABOUT CO-PAY NO CO-PAY FOR THESE SERVICES
Clinic Visits $3.00Outpatient clinics in hospitals or freestanding clinics such as community health centers Mental Health Clinics,Family Planning/Prenatal Services,Alcohol, Drug Abuse,Methadone Clinic,Tuberculosis,Directly Observed Therapy, Developmental Disability,Mental Retardation Clinics,Emergency Care
Brand Name Prescription$2.00One co-payment charge for each new prescription or fiscal order and for each refill NO CO-PAY FOR: Drugs to treat mental illness (psychotropic),Birth Control,Tuberculosis Drugs
Generic Drug Prescription and Over-the-Counter Medications$0.50 One co-payment charge for each new prescription or fiscal order and for each refill NO CO-PAY FOR: Drugs to treat mental illness (psychotropic),Birth Control,Tuberculosis Drugs
Lab Tests$0.50Several co-pays may be charged for one blood test because each test procedure has a co-payNO CO-PAY for pregnancy or prenatal tests
X-Rays$1.00X-Rays in hospital clinics, free-standing clinics and community health clinics NO CO-PAY for x-rays in private doctor's or dentist's offices or for x-rays for emergencies
Medical Supplies$1.00 Syringes, bandages, gloves,sterile irrigation solutions,incontinent pads (diapers),ostomy bags, heating pads, hearing aid batteries, nutritional supplements, etc. NO CO-PAY for birth control supplies,condoms, diaphragms, contraceptive creams
Overnight Hospital Stays$25.00 on the last day One $25 co-payment for each hospitalization of any length involving at least one overnight stay NO CO-PAY for hospital stays for childbirth, miscarriage, family planning services, prenatal care or an emergency condition
Emergency Room$3.00 Co-pay is only for non-urgent or non-emergency services NO CO-PAY for urgent or Emergency services received in an emergency room
Private Doctor's or Dentist's OfficeNo Co-payNo Co-pay NO CO-PAY for services provided in a private doctor's/dentist's office.

TABLE OF MEDICAID RECIPIENTS WHO ARE EXEMPT FROM THE CO-PAYMENT PROGRAM

Under the Legislation, recipients who are eligible for both Medicare and Medicaid, and/or receive SSI (Supplemental Security Income) payments, are not exempt from Medicaid co-payments, unless they also fall under one of the following categories of people that are exempt.

CATEGORIES OF PEOPLE EXEMPT FROM MEDICAID CO-PAYS HOW TO KNOW A RECIPIENT IS EXEMPT FROM MEDICAID CO-PAYS
Persons under 21 years oldMedicaid benefit card shows date of birth. If the card has the wrong birthdate, contact the recipient who then must contact his/her caseworker
Pregnant women are exempt during the pregnancy and for four months after the month in which the pregnancy ends. *Recipient must have a doctor's note OR look pregnant OR the pregnancy is obvious from the type of service or prescription OR you can call the recipient's doctor to verify the pregnancy. You must indicate the appropriate co-pay exemption code on your claim.
Anyone enrolled in a Health Maintenance Organization (HMO) or another Managed Care Program. An insurance code EMEVS indicates the recipient is in an HMO or other managed care program.
Anyone enrolled in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination Program. An exception code** on EMEVS indicates a recipient is in a CMCM or Service Coordination Program.
Nursing Home residents.Nursing Home residents are not subject to co-pay.
Residents of an Intermediate Care Facility for the Developmentally Disabled (ICF/DD). An exception code** on the Medicaid computer system indicates that the recipient lives in an ICF.
Residents of OMH (Office of Mental Health) and OMRDD(Office of Mental Retardation & Developmental Disabilities) certified Community Residences (CR). *CR staff must give residents proof of residence (a letter) to show the pharmacist, clinic and other providers. A new letter must be used on a monthly basis. You must indicate the appropriate co-pay exemption code on your claim.
Recipients enrolled in OMH and OMRDD Home and Community Based Services (HCBS) Waiver Programs. This category does not include adult homes. An exception code** on EMEVS tells providers that the person is an HCBS Waiver participant. In some cases, the case manager of the waiver program must give the enrollee proof of participation (a letter) to show the pharmacist, clinic or other providers.
Recipients enrolled in the Department of Health (DOH) Home and Community Based Services (HCBS) Waiver Program for Persons with Traumatic Brain Injuries (HCBS/TBI Waiver). An exception code** on the Medicaid computer tells providers that the recipient is an HCBS/TBI Waiver participant.

*Please see the billing section of your Provider Manual to find instructions for entering the appropriate co-payment exception code on your claim, or contact CSC at one of the following numbers:

Practitioner Services   (800) 522-5518  (518) 447-9860
Institutional Services  (800) 522-1892  (518) 447-9810
Professional Services   (800) 522-5535   (518) 447-9830

**Exception codes are found in the New York State EMEVS Provider Manual.

If you have any questions regarding this article, please contact the Medicaid Co-Payment Hotline at 1 (800) 451-2831.


THE DEPARTMENT'S WEB SITE OFFERS EASY ACCESS
For You and Your Consumers!
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This is to remind providers that useful information about the New York State Medicaid Program is available on the Department's web site at:
http://www.health.state.ny.us/health_care/medicaid/index.htm

Among the items posted is the Medicaid pamphlet"Need Help Paying for Medical Care? How Medicaid Helps You & Your Family," that may be accessed at:
http://www.health.state.ny.us/health_care/medicaid/

Medicaid Income and Resource Levels , providing consumers a benchmark in the eligibility process, as well as guidance for consumers on how to apply for Medicaid are included at this site.

Applications for Medicaid are made at the local department of social services in the applicant's county of residence:
To assist your consumers the complete listing of county offices, including address and telephone number, may be found at: http://www.health.state.ny.us/health_care/medicaid/ldss.htm

If the applicant resides in New York City, the New York City Human Resources Administration's web site will link the individual to the Medicaid offices in New York City at:
http://www.nyc.gov/html/hra/pdf/medicaid_offices.pdf

Applicants must provide documentation of all available or potentially available income and resources and other eligibility requirements when applying forMedicaid. AA review by local department of social services staff of the documentation determines whether an applicant qualifies for Medicaid.

Consumers are welcome to write to us Questions may be submitted to the Medicaid Mailbox at:

(Please note that this Department will not make a determination as to anyone's eligibility for assistance. The local department of social services in the applicant's county of residence makes this determination.)

Both providers and consumers can make use of the Department's listing of Important Telephone Numbers at:
http://www.health.state.ny.us/health_care/medicaid/program/contact.htm

Included are the toll free numbers to report Medicaid fraud, inquire about co-payment requirements or Medicaid managed care issues, or to receive help on Medicaid billing questions.

We encourage providers to visit this web site for useful information and encourage you to share information with your consumers. The Department will continue to update and enhance this web site to provide up-to-date information.


NOW YOU ARE ENROLLED...LEARN HOW TO BILL SUCCESSFULLY
Schedule of Medicaid Seminars for New Providers
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Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:

  • Overview of MMIS
  • Explanation of MMIS Provider Manual
  • Discussion of Medicaid Managed Care
  • Overview of Billing Options
  • Explanation of 90-day Regulation
  • Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend:

September 13, 2001  10 AM
Cattaraugus County Building
1701 Lincoln Avenue
Olean, NY

October 25, 2001  10 AM
Orleans County Building
14016 Route 31 West
Albion, NY

October 30, 2001  10 AM
Nassau County Department of Social Services
Mineola, NY

Additional seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.

Please register early to attend sites marked with (*) because seating is limited. Each seminar will last approximately two hours.

If the seminar address is not listed above, a CSC representative will contact you at least 2 weeks prior to the seminar date to confirm attendance and provide seminar address information

Direct questions about these seminars to CSC as follows:

Practitioner Services   (800) 522-5518   (518) 447-9860
Institutional Services   (800) 522-1892   (518) 447-9810
Professional Services   (800) 522-5535   (518) 447-9830

Please complete the registration information using the link to the form below:

To register, please mail this completed page to:

Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, fax a copy of the completed page to: 518-447-9240

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.


DURABLE MEDICAL EQUIPMENT PROVIDERS
Coding and Fee Changes

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Effective July 1, 2001, the following fees, codes and prior approval status are applicable:

CODEPRODUCTPRICE
A4640#Replacement pad for use with medically necessary alternating pressure pad owned by patient$38.33
E0371Non-powered advanced pressure reducing overlay for mattress, standard mattresss length and width $3801.20
Z4753Head protector, helmet, hard$76.49

Codes in italics require prior approval; "#" indicates EMEVS Dispensing Validation System (DVS) authorization is required; and bold indicates a new code.

PRESSURE REDUCING SUPPORT SURFACES

Medicaid reimbursement for pressure reducing support surfaces is based on the following coding assignments and coverage criteria:

Group 1


A4640   E0181   E0185  E0187  E0197   E0199
E0180   E0184   E0186   E0196   E0198

  • Completely immobile, i.e., patient cannot make changes in body position,or
  • Limited mobility, i.e., patient cannot independently make changes in body position significant enough to alleviate pressure andhas any stage pressure ulcer on the trunk or pelvis and one of the following: impaired nutritional status, fecal or urinary incontinence, altered sensory perception or compromised circulatory status.

Group 2

E0193  E0277   E0317

  • Multiple Stage II pressure ulcers located on trunk or pelvis, patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate Group 1 support surface and the ulcers have worsened or remained the same over the past month, or
  • Large or multiple Stage III or IV pressure ulcers on the trunk or pelvis, or
  • Recent myocutaneous flap or skin graft surgery (past 60 days) for a pressure ulcer on the trunk or pelvis and the patient has been on at least a Group 2 support surface immediately prior to a recent discharge (past 30 days) from a hospital or nursing home.

If you have any questions regarding this article, please contact the Bureau of Medical Review and Payment at (518) 474-8161.


The Medicaid Update: Your Window Into The Medicaid Program

The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us)

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.state.ny.us/health_care/medicaid/program/main.htm

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