DOH Medicaid Update April 2002 Vol. 17, No. 4

Office of Medicaid Management
DOH Medicaid Update
April 2002 Vol. 17, No. 4

State of New York
George E. Pataki, Governor

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

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

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When you, as a Medicaid provider of service, accept a patient as a Medicaid recipient (as fee-for-service or managed care) and provide a Medicaid covered service, you are prohibited from requesting any monetary compensation for that service from that individual or his/her responsible relative except for Medicaid co-payments. If, for example, the provider sees a patient, advises him/her that the Medicaid card or Medicaid managed care card is valid and eligibility exists for the date of service and then treats the individual, the provider may not change his/her mind and bill the patient for that service.

Further, Medicaid providers are prohibited from referring Medicaid recipients to a collection agency for unpaid medical bills when the provider has accepted the individual as a Medicaid recipient and submitted the bill to the Medicaid fiscal agent, Computer Sciences Corporation (CSC), or the participating Medicaid managed care plan (MMCP) for payment.

Similarly, the provider may not bill the individual in cases where he/she was treated as a Medicaid recipient but the provider failed to submit a claim to CSC or the MCCP for payment within the required time frames.

If a problem arises as a result of submitting a claim, the provider should first contact CSC or the MMCP. If CSC or the MMCP is not able to resolve the issue because some action must be taken by the fiscally responsible local department of social services, such as providing the claiming address of a health insurance company or terminating a closed health insurance policy, the provider must contact the local department of social services for resolution. When the MMCP is involved, providers should work with the MMCP to resolve the outstanding issue.

The policies in this article do not apply to the collection of Medicaid co-payments. Providers may use any legal means to collect unpaid co-payments.

Questions? Contact the Bureau of Program Guidance at (518) 474-9219, or the Bureau of Managed Care Certification and Surveillance at (518) 473-4842.

Summary of Guidelines for the
Diagnosis and Management of Asthma
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The National Institutes of Health, Heart, Lung, and Blood Institutes, Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, (April 1997), updates the first expert panel report published in 1991. It identifies four disease-management strategies and details guidelines for implementation that will keep asthma under control and greatly improve the quality of life for people with the disease. The four strategies include: measurements of assessment and monitoring, control of factors contributing to asthma severity, pharmacologic therapy, and education for a partnership in asthma care. The strategies are briefly summarized below. The complete guidelines are available at:

Component 1..........Measures of Assessment and Monitoring;


Initial Assessment & Diagnosis of Asthma

Making the correct diagnosis of asthma is extremely important. Clinical judgment is required because signs and symptoms vary widely from patient to patient as well as within each patient over time. To establish the diagnosis of asthma, the clinician must determine that:

  • Episodic symptoms of airflow obstruction are present
  • Airflow obstruction is at least partially reversible
  • Alternative diagnoses are excluded

Asthma severity classifications reflect the clinical manifestations of asthma. They are: mild intermittent, mild persistent, moderate persistent, and severe persistent. The panel emphasizes that patients at any level of severity can have mild, moderate, or severe exacerbations.

Periodic Assessment and Monitoring

To establish whether the goals of asthma therapy have been achieved, ongoing monitoring and periodic assessment are needed. The goals of asthma therapy are to:

  • Prevent chronic and troublesome symptoms
  • Maintain (near) normal pulmonary function
  • Maintain normal activity levels (including exercise and other physical activity)
  • Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits and hospitalizations
  • Provide optimal pharmacotherapy (i.e., medication) with minimal or no adverse effects
  • Meet patients' and families' expectations of, and satisfaction with, asthma care

Several types of monitoring are recommended:

  • Signs and symptoms
  • Pulmonary functions
  • Quality of life/functional status
  • History of asthma exacerbations
  • Medications
  • Patient-provider communication
  • Patient satisfaction

The Panel recommends that patients, especially those with moderate-to-severe persistent asthma or a history of severe exacerbations, be given a written action plan based on signs and symptoms and/or peak expiratory flow. Daily peak flow monitoring is recommended for patients with moderate-to-severe persistent asthma. In addition, the Panel states that any patient who develops severe exacerbations may benefit from peak flow monitoring.

COMPONENT 2..........Control of Factors Contributing to Asthma Severity

Exposure of sensitive patients to inhalant allergens has been shown to increase airway inflammation, airway hyperresponsiveness, asthma symptoms, need for medication, and death due to asthma. Substantially reducing exposures significantly reduces these outcomes. Environmental tobacco smoke is a major precipitant of asthma symptoms in children, increases symptoms and the need for medications, and reduces lung function in adults. Increased air pollution levels of respirable particulates, ozone, sulfur dioxide and nitrogen dioxide have been reported to precipitate asthma symptoms and increase emergency department visits and hospitalizations for asthma. In addition to irritants (e.g., tobacco smoke and pollutants) and occupational exposures, reducing exposure to allergens may be required for successful long-term management of asthma. Examples of inhalant allergens include: animal allergens, house-dust mites, cockroach allergens, indoor fungi (molds) and outdoor allergens. Other factors that can contribute to asthma severity include rhinitis and sinusitis, gastroesophageal reflux, some medications, and viral respiratory infections.

COMPONENT 3..........Pharmacologic Therapy


The updated Guidelines offer an extensive discussion of the pharmacological management of patients at all levels of asthma severity. It is noted that asthma pharmacotherapy should be instituted in conjunction with environmental control measures to factors known to increase the patient's asthma symptoms.

A stepwise approach to pharmacologic therapy is recommended, with the type and amount of medication dictated by asthma severity. The updated Guidelines continue to emphasize that persistent asthma requires daily long-term therapy in addition to appropriate medications to manage the asthma exacerbations. Medications are classified into two general classes: long-term-control medications to achieve and maintain control of persistent asthma and quick-relief medications to treat symptoms and exacerbations.

Observations into the basic mechanisms of asthma have had a tremendous influence on therapy. Because inflammation is considered an early and persistent component of asthma, therapy for persistent asthma must be directed toward long-term suppression of inflammation. Thus, the most effective medications for long-term control are those shown to have anti-inflammatory effects. For example, early intervention with inhaled corticosteroids can improve asthma control and normalize lung function, and preliminary studies suggest that it may prevent irreversible airway injury. The updated guidelines also include discussion of the management of asthma in infants and young children that incorporate recent studies on wheezing in early childhood. Another addition is discussions of long-term-control medications that have become available since 1991.

COMPONENT 4..........Education for Partnership in Asthma Care


Education for an active partnership with patients remains the cornerstone of asthma management and should be carried out by health care providers delivering asthma care. Education should start at the time of asthma diagnosis and be integrated into every step of clinical asthma care. Asthma self-management education should be tailored to the needs of each patient, maintaining a sensitivity to cultural beliefs and practices, and involving family members, particularly for pediatric and elderly patients. New emphasis is placed on evaluating outcomes in terms of patient perceptions of improvement, especially quality of life and the ability to engage in usual activities. Health care providers need to systematically teach and frequently review with patients how to manage and control their asthma. Patients also should be provided with and taught to use a written daily self-management plan and an action plan for exacerbations. It is especially important to give a written action plan to patients with moderate-to-severe persistent asthma or a history of severe exacerbations. Appropriate patients should also receive a daily asthma diary. Adherence should be encouraged by promoting open communication; individualizing, reviewing, and adjusting plans as needed; emphasizing goals and outcomes; and encouraging family involvement.

Source: National Institutes of Health, Action Against Asthma, A Strategic plan for the Department of Health and Human Services, May, 2000,

The New York State Medicaid Program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of asthma. For more information, please contact the Bureau of Program Guidance at (518) 474-9219.

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People with diabetes have a two- to four- fold increase in the risk of dying from the complication of cardiovascular disease. Both men and women are at increased risk. Atherosclerosis and vascular thrombosis are major contributors; and platelets are contributory. Investigators have evidence of excess thromboxane (a potent vasoconstrictor and platelet aggregant) release in type 2 diabetic patients with cardiovascular disease. Aspirin blocks thromboxane synthesis and has been used as a primary and secondary strategy to prevent cardiovascular events in non-diabetic and diabetic individuals. Meta-analysis and large-scale collaborative trials in men and women with diabetes support the view that low-dose aspirin therapy should be prescribed for secondary prevention, if no contraindications exist. Low-dose aspirin therapy should also be used for primary prevention in men and women with diabetes who are at high risk for cardiovascular events.

Aspirin Therapy Recommendations

  • Use aspirin therapy as a secondary prevention therapy in diabetic men and women who have evidence of large vessel disease. This includes diabetic men and women with a history of myocardial infarction, vascular bypass procedure, stroke, or transient ischemic attack, peripheral vascular disease, claudication, and/or angina.
  • In addition to treating the primary cardiovascular risk factor(s) identified, consider aspirin therapy as a primary prevention therapy strategy in high-risk men and women with type 1 or type 2 diabetes. This includes diabetic patients with the following:
    • A family history of coronary heart disease
    • Cigarette smoking
    • Hypertension
    • Obesity (>120% desirable weight); BMI >27.3 in women, >27.8 in men
    • Albuminuria (micro or macro)
    • Lipids:
      • Cholesterol >200mg/dl
      • LDL cholesterol <45 MG/DL IN MEN AND <55 MG/DL IN WOMEN
      • Triglycerides >200 mg/dl
      • Age > 30 (Please note: Use of aspirin has not been studied in diabetic individuals under the age of 30 years)
    • Use enteric-coated aspirin in doses of 81-325 mg/day.
    • People with aspirin allergy, bleeding tendency, anticoagulant therapy, recent gastrointestinal bleeding, and clinically active hepatic disease are not candidates for aspirin therapy.
    • Aspirin therapy should not be recommended for patients under the age of 21 years because of the increased risk of Reye's syndrome associated with aspirin use in this population.

Source: Diabetes Care, Volume 25: Supplement 1, January 2002, pgs. S78-S79.

For more information on diabetes, and a complete text of American Diabetes Association Clinical Practice Recommendation, 2002, go to:

The Medicaid Program reimburses for medically necessary care, services and supplies for the diagnosis and treatment of diabetes. For information regarding Medicaid coverage of services related to diabetes, contact the Bureau of Program Guidance at (518) 474-9219, or please go to:

No Smoking No Smoking

Smoking Cessation Coverage Highlights
New York State Medicaid
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  • Smoking cessation therapy consists of prescription and non-prescription agents. Covered agents include nicotine patches, inhalers, nasal sprays, gum, and Zyban (bupropion).
  • Two courses of smoking cessation therapy per recipient, per year are allowed. A course of therapy is defined as no more than a 90-day supply (an original prescription and two refills, even if less than a 30 day supply is dispensed in any fill).
  • Multiple smoking cessation therapies, using different routes of administration, are allowed (e.g., Zyban and nicotine patches may be used concomitantly, if warranted). Professional judgment should be exercised when dispensing multiple smoking cessation products.
  • Duplicative use of any one agent is not allowed (i.e., same drug/same dosage form/same strength).

An additional support available to Medicaid recipients is a toll-free smoking help-line staffed by employees of the Roswell Park Cancer Institute.

  • The Quitline offers smokers a confidential and convenient way to access immediate help when they are ready to stop smoking or need support to remain smoke-free.
  • Health care providers can also call the Quitline to obtain office materials that can be shared with patients.


1-866-NYQUITS (1-866-697-8487)

If you would like more information about the Medicaid Program's Smoking Cessation Initiative, please contact the Bureau of Program Guidance at (518) 474-9219.

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 below:

May 15, 2002 10:30 AM
Suffern Free Library
210 Lafayette Avenue
Suffern, NY

June 12, 2002 10 AM
Dutchess County Dept. of Social Services
60 Market Street
Poughkeepsie, NY

July 17, 2002 10 AM
Washington County Municipal Center
Building B, Training Room
383 Broadway
Fort Edward, NY

July 23, 2002 10:30 AM or 1:30 PM
Clinton County Dept. of Social Services
First Floor Conference Room
13 Durkee Street
*Plattsburgh, 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.

Direct questions about these seminars to CSC as follows:

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

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.

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The New York State Department of Health is changing the Medicaid managed care benefit package for chemical dependence (alcohol and substance abuse) services.

  • Effective April 1, 2002, Alcohol Outpatient Clinic services will no longer be included in the benefit package provided by managed care plans.
    Medicaid managed care enrollees will obtain these services through the Medicaid fee-for-service program. As required for other Medicaid covered services excluded from the Medicaid managed care benefit package, enrollees will use their Medicaid card to obtain services from qualified Medicaid providers.
  • Medicaid managed care plans may offer new community based detoxification services.The New York State Office of Alcohol and Substance Abuse Services are licensing Medically Supervised Inpatient and Outpatient Withdrawal Service Programs. These new community based detoxification programs offer alternatives to detoxification services provided in acute inpatient hospitals licensed under Article 28 of the Public Health Law. As these community-based services become available, Medicaid managed care plans may choose to use them as alternative sites for providing detoxification services.
  • Effective April 1, 2002, the Medicaid managed care benefit package still includes the following chemical dependence (alcohol and substance abuse) services:
    • For enrollees in non-SSI Medicaid-eligible aid categories:
      • Chemical dependence inpatient rehabilitation and treatment programs.
      • Detoxification services including Medically Managed Acute Detoxification and, where available, Medically Supervised Inpatient and Outpatient Withdrawal Services.
      • One calendar year self-referral for a chemical dependence assessment by a plan inpatient rehabilitation and treatment or detoxification provider.
    • For enrollees who are in receipt of SSI (Supplemental Security Income) or who are in a SSI-related aid category:
      • Detoxification services including Medically Managed Acute Detoxification and, where available, Medically Supervised Inpatient and Outpatient Withdrawal Services.

If you have questions about the new Medicaid Managed Care Benefit Package, please contact Barbara Frankel or Ilyana Meltzer at (518) 473-7467.

If you have questions about the Office of Alcohol and Substance Abuse Services' (OASAS) new community-based detoxification services, and any other chemical dependence programs, please contract Greg Allen or Marie Spada at (518) 485-2207.

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In order to receive payments from New York State Medicaid, providers are required to inform the Medicaid Program within fifteen (15) days of any change in direct or indirect ownership or control interest in the enrolled provider.

For Medicaid purposes, an ownership or control interest means a person or corporation that:

  • Has an ownership interest totaling five percent (5%) or more in a disclosing entity;
  • Has an indirect ownership interest equal to five percent (5%) or more in a disclosing entity;
  • Has a combination of direct and indirect ownership interests equal to five percent (5%) or more in a disclosing entity;
  • Owns an interest of five percent (5%) or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least five percent (5%) of the value of the property or assets of the disclosing entity;
  • Is an officer or director of a disclosing entity that is organized as a corporation; or
  • Is a partner in a disclosing entity that is organized as a partnership.

Ownership interest is defined as possession of equity in the capital, the stock or the profits of a provider.

Changes of ownership or control interest must be reported to the New York State Department of Health, Office of Medicaid Management, by filing an amended, signed ownership and control interest disclosure form.

Based upon the information supplied, you may also be required to complete a new Medicaid Provider Enrollment Application to reflect the structural change to your business.

Copies of the required disclosure forms for fee-for-service providers such as physicians, dentists, pharmacies and durable medical equipment dealers may be obtained from:

New York State Department of Health
Office of Medicaid Management
Bureau of Enrollment
99 Washington Avenue, Suite 611
Albany, New York 12210

Copies of the required disclosure forms for institutional providers such as hospitals, nursing homes, home health agencies and freestanding clinics may be obtained from:

New York State Department of Health
Bureau of Medical Review and Payment
ATTN: Provider Enrollment
99 Washington Avenue, Suite 800
Albany, New York 12210

Questions? Fee-for-service providers call (518) 486-9440. Institutional providers call (518) 474-8161.

List of Operational Managed Long Term Care Providers
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The Department of Health uses several long term care providers to deliver medical care to Medicaid recipients under a managed care setting. You will be alerted that a certain recipient is in a managed care program when you use the Electronic Medicaid Eligibility Verification System (EMEVS) to determine a patient's Medicaid eligibility.

When you see one of the following Plan Codes, you will be treating a person who is covered under Medicaid managed long term care. If you need information from the plan, contact the pertinent person below.

Managed Long Term Care ProviderPlan CodeContactAddress Telephone
CHRONIC CARE MANAGEMENT CORPORATION C7 Susan Aldrich, Vice President 612 Allerton Avenue Bronx, NY 10467 (718) 519-5925
INDEPENDENT LIVING FOR SENIORS IL Joanne Tallinger, Administrator 2066 Hudson Avenue Rochester, NY 14617 (585) 922-2836
INDEPENDENT LIVING SERVICES IS Penny Abulencia, Director 700 East Brighton Avenue Syracuse, NY 13205 (315) 469-5570
EDDY SENIOR CARE E7 Gary Kozick, Director 504 State Street Schenectady, NY 12305 (518) 382-3290
VNS CHOICE VC Holly Fisher, Vice President for Long Term Care 5 Penn Plaza, 11th floor, New York, NY 10001 (212) 290-4858
CO-OP CARE AN Suzanne Brown, Director of Managed Care 2117 Williams Bridge Rd. Bronx, NY 10461 (718) 239-6686
PARTNERS IN COMMUNITY CARE GD Arnie Green, Administrator 255 Lafayette Ave. Suffern, NY 10901 (845) 368-5930
HOME FIRST, INC. AW Chris Palmieri, Project Director 6323 Seventh Ave, Brooklyn, NY 11220 (718) 921-7835
GUILDNET GN Geri Taylor, Executive V.P. 15 W 65th St. New York, NY 10023 (212) 769-7851
INDEPENDENCE CARE SYSTEM IX Richard Surpin, President 257 Park Ave., South New York, NY 10010 (212) 584-2500
HEALTH ADVANTAGE PLAN M3 Maureen Coughlin 6 Harriman Drive Goshen, NY 10924 (845) 569-0500
SENIOR HEALTH PARTNERS H1 Chris Klotz, President & CEO 149 West 105th St., Suite 3E New York, NY 10025 (212) 870-5038
BROADLAWN HEALTH PARTNERS LE Diane Dias, Administrator 399 County Line Road Amityville, NY 11701 (631) 608-5630
SENIOR NETWORK HEALTH MZ Mary Kate Rolfe, Program Director 1724 Burrstone Road New Hartford, NY 13413 (315) 272-2100


The month of May is...

Asthma and Allergy Awareness Month?
Contact: Allergy and Asthma Network
(800) 878-4403

Hepatitis Awareness Month?
Contact: Hepatitis Foundation International
(800) 891-0707

National Arthritis Month?
Contact: Arthritis Foundation
(800) 283-7800

National Osteoporosis Prevention Month?
Contact: National Osteoporosis Foundation
(800) 223-2226

For a complete calendar
of all national health
observances, call:
National Wellness Institute
(715) 342-2969,
Or on the internet at:

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:

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:

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:

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:

Applicants must provide documentation of all available or potentially available income and resources and other eligibility requirements when applying for Medicaid. A 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:

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.

Indexed Medicaid Update Articles For 2001!
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Did you miss a pertinent article during the year 2001? Listed below is an index of articles, by provider specialty or subject area. These articles can be located:

Please note that articles containing invitations to provider seminars are not listed, as these events have already occurred.

Please note that articles containing invitations to provider seminars are not listed, as these events have already occurred.


All Providers


Care At Home

Child Care Agencies


Clinical Psychology

Clinical Social Worker


Durable Medical Equipment

Family Health Plus

Hearing Aid




Managed Care



Nurse Practitioner



Ordered Ambulatory




Service Bureaus/Billing Services

Tobacco Cessation

Traumatic Brain Injury (TBI) Waiver

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 )

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: