DOH Medicaid Update February 2007 Vol. 22, No. 2

Office of Medicaid Management
DOH Medicaid Update
February 2007 Vol. 22, No. 2

 

State of New York
Eliot Spitzer, Governor

Medicaid Update
is a monthly publication of the
New York State Department of Health

Office of Health Insurance Programs
Deborah Bachrach, Deputy Commissioner

 


Expansion of the Preferred Drug Program
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The Medicaid Preferred Drug Program (PDP) is expanding to include additional drug classes. Prescriptions written on or after February 1, 2007, for non-preferred drugs in the following drug categories, will require prior authorization:

Pills

  • Inhaled Beta 2 Adrenergic Agents-Short Acting
  • Inhaled Beta 2 Adrenergic Agents-Long Acting
  • Inhaled Anticholinergics
  • Inhaled Corticosteroids
  • Phosphate Binders/Regulators
  • Topical Immunomodulators
  • Anti-fungals
  • Anti-virals
  • Fluoroquinolones (oral)
  • Third Generation Cephalosporins

Prescribers are required to complete the prior authorization process prior to prescribing non-preferred drugs.

To obtain prior authorization for a non-preferred drug, contact the staffed Clinical Call Center at 1-877-309-9493 and follow the appropriate prompts.

The most current Preferred Drug List can be found at:

http://www.nyhealth.gov or http://newyork.fhsc.com

For clinical concerns or preferred drug program questions, contact 1-877-309-9493.

For billing questions, contact 1-800-343-9000.

For Medicaid pharmacy policy and operations questions, call (518) 486-3209


New York State Medicaid
Preferred Drug List
All non-preferred drugs in these classes will require prior authorization.
Return to Table of Contents

ACE InhibitorsACE Inhibitors
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Altace®
benazepril
captopril
enalapril maleate
lisinopril
Mavik®
moexipril
Accupril®
Aceon®
Capoten®
fosinopril sodium
Lotensin®
Monopril®
Prinivil®
quinaprill
Univasc®
Vasotec®
Zestril®
ACE Inhibitors + Calcium Channel BlockerACE Inhibitors + Calcium Channel Blocker
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Lotrel ®
Tarka®
Lexxel®
ACE Inhibitors + DiureticAce Inhibitors + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
benazepril/HCTZ
captopril/HCTZ
enalapril maleate/HCTZ
lisinopril/HCTZ
Unieretic®
Accuretic®
Capozide®
fosinopril HTC
Lotensin HCT®
Monopril HCT®
Prinzide®
quinapril/HCTZ
Quinaretic®
Vaseretic®
Zestoretic®
Angiotensin Receptor Blockers Angiotensin Receptor Blockers
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Benicar®®
Cozaar®
Diovan®
Micardis ®
Atacand®
Avapro®
Teveten®
Angiotensin Receptor Blocker + DiureticAngiotensin Receptor Blocker + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Benicar HTC®
Diovan HTC®
Hyzaar®
Micardis HCT®
Atacand HCT®
Avalide®
Teveten HCT®
Anti-Emetics - OralAnti-Emetics - Oral
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Kytril®(tablet, solution)
Zofran®(tablet, solution, ODT)
Anzemet®
Anti-FungalsAnti-Fungals
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Fulvicin U/F®
Grifulvin V® (tablet)
Gris-PEG®
griseofulvin (suspension)
Lamisil®
Grifulvin V® (suspension)
itraconazole (capsule)
Penlac®
Sporanox® (capsule, solution)
Antihistamines - Second Generation Antihistamines - Second Generation CC
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
OTC loratadine
OTC loratadine-D
Allegra®
Allegra-D®
Clarinex®
Clarinex-D®
fexofenadine
Semprex-D®
Zyrtec®CC
Zyrtec-D®
Anti-Virals Anti-ViralsCC
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
acyclovir (tablet, capsule, suspension)
Famvir®
Valtrex®
Zovirax® (tablet, capsule, suspension)
Beta BlockersBeta Blockers CC
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
acebutolol
atenolol
betaxolol
bisoprolol funerate
labetalol
metoprolol tartrate
nadolol
pindolol
propranolol
timolol maleate
Blocadren®
Coreg®CC
Coreg CR®CC
Corgard®
Inderal LA®
Inderal®
InnoPran XL®
Kerlone®
Lopressor®
Levatol®
Sectral®
Tenormin®
Toprol XL®CC
Trandate®
Zebeta®
Beta Blocker + DiureticBeta Blocker + Diuretic
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
atenolol/chlorthalidone
bisoprolol funerate/HCTZ
metoprolol tartrate/HCTZ
propranolol/HCTZ
Corzide®
Inderide®
Inderide LA®
Lopressor HCT®
Tenoretic®
Timolide®
Ziac®
Bisphosphonates - OralBisphosphonates - Oral
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Fosamax®(tablet, solution)
Fosamax®Plus D
Actonel®
Actonel®with Calcium
Boniva®
Calcitonins - NasalCalcitonins - Nasal
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Miacalcin® Fortical®
Calcium Channel Blockers (DHP)Calcium Channel Blockers (DHP)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 6/28/06
Afeditab CR®
Dynacirc ®
Dynacirc CR®
felodipine ER
isradipine
nicardipine HCL
Nifediac CC®
Nifedical XL®
nifedipine
nifedipine ER
nifedipine SA
Norvasc®
Sular®
Adalat CC®
Cardene®
Cardene SR®
Plendil®
Procardia®
Procardia XL®
Cephalosporins - Third GenerationCephalosporins - Third Generation
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Cedax®(capsule, suspension)
cefpodoxime proxetil (tablet)
Omnicaf®(capsule, suspension)
Suprax®
Spectracef®
Vantin® (tablet, suspension)
Fluoroquinolones (Oral)Fluoroquinolones (Oral)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Avelox®
Avelox ABC Pack®
ciprofloxacin (tablet, suspension)
ofloxacin
Cipro® (tablet, suspension)
Cipro XR®
Factive®
Floxin®
Levaquin® (tablet, suspension)
Maxaquin®
Noroxin®
Proquin XR®
Tequin®
Hepatitis C AgentsHepatitis C Agents
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
PEG-Intron®
PEG-Intron Redipen®
Pegasys®
Pegasys Convenience Pack®
None
HMG-CoA Reductase Inhibitors (Statins)HMG-CoA Reductase Inhibitors (Statins)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Advicor®
Altoprev®
Crestor®
Lescol®
Lescol XL
Lipitor®
Vytorin®
Zocor®
Caduet®
lovastatin
Mevacor®
Pravachol®
prevastatin
PravigardPAC®
Immunomodulators (Topical)Immunomodulators (Topical)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Elidel®
Protopic®
None
Inhaled AnticholinergicsInhaled Anticholinergics
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Atrovent®
Atrovent HFA®
Combivent®
ipratropium
Spiriva®
Duoneb®
Inhaled beta2Adrenergic Agents - Long ActingInhaled beta2Adrenergic Agents - Long Acting
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Foradil®
Serevent Diskus®
None
Inhaled beta2Adrenergic Agents - Short ActingInhaled beta2Adrenergic Agents - Short Acting
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
albuterol
Maxair Autohaler®
Proventil HFA®
Ventolin HFA®
Xopenex®
Xopenex HFA®
Accuneb®
Alupent®
metaproterenol
ProAir HFA®
Proventil®
Inhaled CorticosteroidsInhaled Corticosteroids
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Advair Diskus®
Advair HFA®
Asmanex®
Azmacort®
Flovent HFA®
Qvar®
Aerobid®
Aerobid-M®
Pulmicort Turbuhaler®CC
Leukotriene ModifiersLeukotriene Modifiers
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Accolate®
Singular®
None
Narcotics - Long ActingNarcotics - Long Acting
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Duragesic®
fentanyl patch
Kadian®
morphine sulfate SR
Oramorph SR®
Avinza®
MS Contin®
Opana ER®
oxycodone HCL CR
Oxycontin®
Phosphate Binders/RegulatorsPhosphate Binders/Regulators
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 2/01/07
Fosrenol®
Phoslo
Renagel®
None
Proton Pump InhibitorsProton Pump Inhibitors
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Nexium®
Prevacid®(capsule)
Prilosec®OTC
Aciphex®
omeprazole
Prevacid NapraPAC®
Prevacid® (solutab, suspension)

Prilosec®
Protonix®
Zegerid® (capsule, packet)
Sedative Hypnotics/Sleep AgentsSedative Hypnotics/Sleep Agents
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Ambien CR®
chloral hydrate
estazolam
flurazepam
temazepam
triazolam
Ambien®
Dalmane®
Doral®
Halcion®
Lunesta®
Prosom®
Restoril®
Rozerem®
Somnote®
Sonta®
Serotonin Receptor Agonists (Triptans)Serotonin Receptor Agonists (Triptans)
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Imitrex®(tablet, nasal, injection)
Maxalt®(tablet, MLT)
Amerge®
Axert®
Frova®
Relpax®
Zomig®(tablet, nasal, ZMT)
Steroids - IntranasalSteroids - Intranasal
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Nasacort AQ®
Nasonex®
Beconase AQ®
Flonase®
flunisolide®
fluticasone®
Nasarel®
Rhinacort Aqua®
ThiazolidinedionesThiazolidinediones
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
Actos®
Actoplus met®
Avandia®
Avandamet®
Avandaryl
Duetact®
Triglyceride Lowering AgentsTriglyceride Lowering Agents
PREFERRED AGENTSNON-PREFERRED AGENTS - PA Required Effective 10/18/06
gemfibrozil
Lofirba®
Antara®
fenofibrate®
Lopid®
Omacor®
Tricor
Triglide

The most current Preferred Drug List can be found at:

http://www.nyhealth.gov or http://newyork.fhsc.com

For clinical concerns or preferred drug program questions, contact 1-877-309-9493.

For billing questions, contact 1-800-343-9000.

For Medicaid pharmacy policy and operations questions, call (518) 486-3209


2007 New York State Medicare Part D
Prescription Drug Plans

For people with both Medicare and NYS Medicaid
Return to Table of Contents

The following is a list of the 2007 Medicare Part D Prescription Drug Plans available to both Medicare and New York State Medicaid recipients at no cost. Other plans offered by these companies may require an additional monthly premium payment.

Contact information was updated December 2006.

  • American Progressive Insurance Co.
  • Prescription Pathway Bronze Plan Reg 3
  • Customer Service 1-800-978-9500
  • Current Members 1-866-566-3052
  • www.RxPathway.com
  • Bravo By Elder Health
  • Bravo Rx II
  • Customer Service 1-800-235-9188
  • Current Members 1-800-935-7193
  • www.elderhealth.com
  • CIGNA Healthcare
  • Cignature Rx Value Plan
  • Customer Service 1-800-735-1459
  • Current Members 1-800-822-6700
  • www.cignature-rx.com
  • HealthSpring Prescription Drug Plan
  • HealthSpring Prescription Drug Plan Reg3
  • Customer Service 1-800-331-6293
  • Current Members 1-866-845-6941
  • www.myhealthspring.com
  • HIP Ins Co of NY
  • HIP Standard Part D New York
  • Customer Service 1-800-447-9169
  • Current Members 1-800-447-8255
  • www.HIPusa.com
  • Humana Insurance Company of NY
  • Humana PDP Standard
  • Customer Service 1-800-706-0872
  • Current Members 1-800-281-6918
  • www.humana-medicare.com
  • RxAmerica
  • Advantage Star Plan by RxAmerica
  • Customer Service 1-877-279-0370
  • Current Members 1-800-429-6686
  • www.Meds4Medicare.com
  • Sterling Prescription Drug Plan
  • Sterling Rx
  • Customer Service 1-866-865-0664
  • Current Members 1-866-865-0664
  • www.sterlingplans.com
  • Unicare (Anthem)
  • Medicare Rx Rewards Value
  • Customer Service 1-800-240-4333
  • Current Members 1-800-928-6201
  • www.unicare.com
  • United Healthcare Insurance Co of NY
  • AARP MedicareRX Plan Saver
  • Customer Service 1-888-867-5575
  • Current Members 1-888-867-5575
  • www.partdcentral.com
  • Wellcare Health Plans
  • Wellcare Classic
  • Wellcare Signature
  • Customer Service 1-888-423-5252
  • Current Members 1-888-550-5252
  • www.wellcarepdp.com

Fully subsidized dual eligible recipients may also choose to enroll in the following prescription drug plans at no premium liability:

  • First Health Premier
  • First Health Part D
  • Customer Service 1-800-588-3322
  • Current Members 1-866-823-4701
  • www.firsthealthpartd.com
  • Health Net
  • Health Net Orange Option 1
  • Customer Service 1-800-606-3604
  • Current Members 1-800-806-8811
  • www.healthnet.com
  • MemberHealth
  • Community Care Rx Basic
  • Customer Service 1-866-684-5353
  • Current Members 1-866-684-5353
  • www.communitycarerx.com

Recipients who need assistance in making choices can receive help by contacting:

  • Medicare: 1-800-MEDICARE
  • CMS Plan Finder: www.medicare.gov
  • Health Insurance Information Counseling Assistance Program (HIICAP): 1-800-701-0501

Or contact the plans listed above directly.


Attention:
Providers Rendering
Family Planning Services
to Recipients Eligible for
the Family Planning Benefit Program

Family Planning Benefit Program
Change in Reimbursement Requirement
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This article is to provide advance notice to providers of healthcare services to Family Planning Benefit Program (FPBP) recipients (those with "family planning services only") that a new reimbursement requirement will be effective beginning May 17, 2007.

The Centers for Medicare and Medicaid (CMS) have mandated that Medicaid ensure that all FPBP claims submitted are limited to family planning services.

To meet this program requirement and for providers to receive reimbursement, all clinic and practitioner claims processed for FPBP recipients, on or after May 17, 2007, must contain a family planning procedure code from the list provided below. In addition the diagnosis code must be in the V25 (contraceptive management) series.

Clinic claims must include both the rate code and a corresponding family planning procedure code(s).

ALL claims submitted for FPBP recipients must contain:

  • A "Y" in the family planning box, if appropriate.
  • A diagnosis code in the V25 series.
  • The appropriate code for the procedure or procedures performed from the list below of approved family planning services or any family planning prescription drugs, over-the counter drugs, or medical and surgical supplies.

Claims processed for an FPBP recipient with a service date on or after May 17, 2007, will be denied if the above information is not on the claim form.

The following is the list of codes approved by CMS for family planning procedures under the Family Planning Benefit Program.

APPROVED CODES FOR SERVICES UNDER THE FAMILY PLANNING BENEFIT PROGRAM
1197571010865928708687390881479300099213J1055
1197671015865938710287430881489301099214J1056
1197781000866318711087490881509304099215J7300
5525081001866898720587491881539304199241J7302
5545081002866968720787535881549907099242J7303
5830081003867018721087536881559920199243J7304
5830181007867028725287590881609920299244 
5856581025867038725487591881629920399245 
58600847038676287270878008816499204A4266 
58615850138678187273878508816599205A4267 
58670850148707087274881418817499211A4268 
58671850258708187320881428817599212Z2351 

Remember, this requirement will not go into effect until May 17, 2007.

Questions? Contact the Bureau of Policy Development and Agency Relations at: (518) 473-2160.


Notice To Hospitals Billing Diagnosis Related Groups
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Annually, the Bureau of Health Economics determines the 20 most frequently billed Diagnosis Related Groups (DRGs). Below is the new DRG table for Medicaid payments to New York State hospitals. The new table is effective for discharges beginning January 1, 2007.

When payment for one of these DRGs is indicated, the remittance statement will list rate code 2996 rather than 2946.

Providers can access the SIW table for New York State hospitals at the following website:

www.health.state.ny.us/facilities/hospital/drg/drgs.htm

Effective discharge date January 1, 2007, the Top 20 DRGs are:

DRG #DIAGNOSIS RELATED GROUP NAME
88CHRONIC OBSTRUCTIVE PULMONARY DISEASE
89SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC
127HEART FAILURE & SHOCK
143CHEST PAIN
183ESOPHAGITIS,GASTROENT & MISC DIGEST DISORD AGE>17 W/O CC
209MAJ JOINT & LIMB REATTACHMENT PROCEDURE OF LOW EXT, EXC HIP, EXC FOR COMP
359UTERINE & ADNEXA PROC FOR CA IN SITU & NONMALIG W/O CC
370CESAREAN SECTION W CC
371CESAREAN SECTION W/O CC
372VAGINAL DELIVERY W COMPLICATING DIAGNOSES
373VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES
494LAPAROSCOPIC CHOLECYSTECTOMY W/O CDE W/O CC
627NEONATE, BWT >2499G, W/O SIGNIF OR PROC, W MAJOR PROB
628NEONATE, BWT >2499G, W/O SIGNIF OR PROC, W MINOR PROB
629NEONATE, BWT >2499G, W/O SIGN OR PROC, W NORM NEWB DIAG
775BRONCHITIS & ASTHMA AGE ‹18 W/O CC
814NONBACTERIAL GASTROENTERITIS & ABDOMINAL PAIN AGE ›17 W/O CC
854PERCUTANEOUS CARDIOVASCULAR PROCEDURE W DRUG-ELUTING STENT W/O AMI
883LAPAROSCOPIC APPENDECTOMY
886OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE

Questions? Contact the Division of Medical Review and Provider Enrollment, Rate Based Provider Unit at: (518) 474-8161.


UPDATE!

New York State
Newborn Screening Program
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The New York State Newborn Screening (NBS) program currently screens all newborn infants in New York State for 45 conditions.

To ensure that screen-positive Medicaid recipients will receive appropriate, medically necessary follow-up care, the NYS Medicaid and NBS programs are jointly developing evidence-based guidelines for follow-up management of many of the 45 conditions currently detected in the NBS program.

Guidelines will address:

Woman and baby

  • specialized confirmatory testing,
  • additional diagnostic tests,
  • specialty consultations,
  • specialized treatments, and
  • long-term follow up.

The first guideline is for management of Krabbe disease, a condition undergoing screening in New York since August 2006 (see the September 2006 Medicaid Update).

Infantile Krabbe Disease requires rapid diagnostic testing to determine whether a cord blood stem cell transplant is indicated. Since the transplant must be completed within the first few weeks of life for a confirmed case, inpatient admission to rapidly complete the initial evaluation sequence is medically necessary for those screen-positive infants with a subsequent positive confirmatory test. For many rare genetic conditions such as Krabbe disease, management or co-management through a Center of Excellence is medically necessary. Repeat testing and surveillance may also be required in certain cases.

As guidelines are completed, they will be posted on the Newborn Screening website at:

http://www.wadsworth.org/newborn/index.htm

Guidelines will be developed with national input from the American College of Medical Genetics as well as input from medical experts throughout NYS and appropriate stakeholder groups.

The guidelines are intended to be flexible; they will serve as recommendations, not rigid criteria.

Depending on the patient and circumstances, the guidelines may need to be tailored to fit individual needs. Medicaid program coverage will include (but is not limited to) those services specified in the guidelines.

Questions may be addressed to the Newborn Screening Program at: (518) 473-7552.

Questions about NYS Medicaid payment for testing and treatment of Krabbe disease and other genetic conditions can be directed to the Division of Medical Review and Provider Enrollment at:(518) 474-8161.


Mandatory Medicaid Managed Care Program Expansion
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The Department of Health has received approval to expand the Mandatory Medicaid Managed Care program to include 14 additional counties.

Expansion counties include:

Meeting

  • Allegany
  • Cortland
  • Dutchess
  • Fulton
  • Montgomery
  • Orange
  • Otsego
  • Putnam
  • Schenectady
  • Seneca
  • Sullivan
  • Ulster
  • Washington
  • Yates

Medicaid providers will be invited to attend a FREE Seminar to be held now through March 2007 in each of the above counties. Some providers may have already attended seminars or registered for upcoming seminars. Providers who would like to attend one of the remaining seminars are encouraged to return their registration from the invitation.

Seminars will include presentations from the State Department of Health and the Computer Sciences Corporation (CSC).

Topics will include:

  • Understanding how managed care may affect Medicaid providers.
  • Interpreting remittance information.
  • Knowing when to bill a Managed Care Organization (MCO).
  • Knowing when to bill Medicaid Fee for Service (FFS) directly.
  • Understanding and Interpreting MEVS messages.

These seminars will give providers a chance to find out how expansion of the mandatory Medicaid Managed Care program may affect them. Representatives from the local social services districts as well as the MCOs will be present to respond to questions. MCOs will also be available to discuss, with non-contracting providers, the steps that should be taken for contracting with their plan to provide services.

Don't miss this important opportunity to have your questions answered!

Please refer to your invitation for location, dates, and times of seminars in your county.

If you did not receive an invitation and are interested in registration information, please contact CSC at: 800-343-9000.


Medicaid Managed Care Disenrollment Process for
Long-Term Home Health Care Program Participants
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Social Services Law and Medicaid regulations prohibit individuals participating in the Long-Term Home Health Care Program (LTHHCP) ("Lombardi" program) from enrolling into a Medicaid Managed Care plan, primarily due to duplication of services.

If an individual meets the eligibility requirements of the LTHHCP and chooses to participate in the program, then he/she must first disenroll from managed care before enrolling in the LTHHCP. Included below is more information on how managed care enrollment occurs and the steps to be followed by LTHHCP providers to facilitate managed care disenrollment when indicated.

Stairs

  • In districts where managed care enrollment is mandatory, most Medicaid recipients must choose a managed care plan or be auto-enrolled in a plan. In other districts, managed care enrollment is voluntary. Either way auto enrollment or voluntary enrollment into a managed care plan is usually prospective (e.g. if the individual enrolls on August 6, 2006 then the typical effective date for the managed care plan to begin is September 1, 2006).
  • When an individual is approved for the LTHHCP/Lombardi program, the New York City Human Resources Administration (HRA), the Local Department of Social Services (LDSS), or the State Department of Health (SDOH) must enter Restriction/Exception (R/E) Code "90 - Managed Care Excluded" on the Welfare Management System (WMS), which prevents mandatory managed care auto enrollment as well as voluntary managed care enrollment. When the new LTHHCP R/E Code 30 (identifies authorized LTHHCP participants) is fully implemented, the presence of R/E Code 30 on the WMS file will also prevent both mandatory managed care auto enrollment as well as voluntary managed care enrollment for LTHHCP participants. When R/E Code 30 is added to a file upon approval of LTHHCP participants. When R/E Code 90 does not need to be removed or inactivated since both can coexist.
  • It is the responsibility of the LTHHCP provider to verify each potential LTHHCP participant's Medicaid eligibility including whether the individual is enrolled in a managed care plan prior to providing LTHHCP services.
  • The following options may be used to determine Medicaid Eligibility and Managed Care Enrollment Status:
    • Verify with the Medicaid recipient whether he/she has enrolled in a managed care plan. If he/she has enrolled then he/she should have received an enrollment letter from either the LDSS or the enrollment broker (New York Medicaid CHOICE). This letter will include enrollment information and the effective start date of the managed care plan and will identify the enrollment broker in the letterhead.
    • Medicaid swipe card or verifone (OMNI 3750): This message type system will indicate if an individual is enrolled in a managed care plan and will specify the plan by name.
    • ePACES: The eligibility response screen will indicate if the individual is enrolled in a managed care plan and will specify the plan by name.
  • Contact Computer Sciences Corp. (CSC) auto response phone number: 1-800-997-1111. This requires entering the individual's CIN # and choosing the option of checking eligibility. If the individual is in a managed care plan, the auto response will indicate PCP (Prepaid Capitation Plan) and will specify the plan code #.

If the individual is already enrolled in a managed care plan, has enrolled with a pending effective start date, or has not yet enrolled in managed care, then the following steps must be taken to prevent enrollment or to disenroll the individual from managed care prior to enrolling into the LTHHCP:

For the counties outside of NYC, Suffolk and Nassau County:

Some local departments of social services have established procedures for LTHHCP providers in the event that a LTHHCP provider needs an action taken on an individual's Medicaid case. If the LTHHCP provider is uncertain about how to proceed with a managed care disenrollment issue, the LTHHCP provider should contact the Managed Care Coordinator at the LDSS.

The following information must be provided: Client's name, CIN #, date the client entered the LTHHCP and LTHHCP Provider agency name, with agency contact name and phone number. The LDSS will then enter the Restriction/Exception Code 90 into the system once LTHHCP participation is verified (if not already on file).

For LTHHCP providers in NYC, Suffolk and Nassau County, or other counties using the enrollment broker:

  • 1. Currently, NYC, Suffolk and Nassau Counties use an enrollment broker, Maximus, which operates as New York Medicaid CHOICE. It is expected that other upstate counties may begin using New York Medicaid CHOICE for managed care enrollments in early 2007. In those counties that use New York Medicaid CHOICE, the LTHHCP provider must notify New York Medicaid CHOICE in writing that the individual needs to be excluded from Managed Care because he/she is authorized for the LTHHCP.

New York Medicaid CHOICE Contact information:

Crystol Epperson
EEU Supervision (Exemption/Exclusion Unit)
New York Medicaid CHOICE
30 Broad Street, 18th Floor
New York, NY 10004
Phone: 917-228-5653
Fax: 917-228-8601

      Written authorization (typed or otherwise legible) must include the following information on agency letterhead:

  • Individual's Name
  • CIN # (Client Identification Number)

  • Indicate that this individual should be excluded/disenrolled from managed care because he/she is authorized for the LTHHCP/Lombardi program
  • Date the client entered the LTHHCP
  • Letter must be signed by authorized agency/provider staff.

Example:

"Agency Letterhead"

Dear New York Medicaid CHOICE/Crystol Epperson:

"The purpose of this letter is to notify New York Medicaid CHOICE (Maximus) that John Doe, CIN # AA00000P is authorized for the LTHHCP/Lombardi program on 9/22/06. Therefore, this individual needs to be excluded from mandatory Medicaid Managed Care enrollment and/or be disenrolled from Managed Care."

  • 2. It is recommended that the LTHHCP provider follow up with a phone call to New York Medicaid CHOICE to confirm that written documentation was received.
  • 3. The LTHHCP provider must also notify HRA/LDSS of any action taken.
  • 4. If the individual is already enrolled in a managed care plan, New York Medicaid CHOICE will enter an exclusion code on their system and disenroll the client prospectively. (e.g., written authorization to disenroll the individual is received by New York Medicaid CHOICE on 8/10/06; therefore the expected effective date of disenrollment would be 8/31/06).
  • 5. If the individual is enrolled with a pending effective start date in managed care (R/E 90 has not been activated on file) or the individual has not yet enrolled in managed care: New York Medicaid CHOICE will enter an exclusion code on their system to prevent future enrollment or delete the pending enrollment.

If you have questions regarding the LTHHCP, contact the Bureau of Long Term Care at: (518) 474-6580.

If you have any questions regarding managed care disenrollment, contact the Managed Care Coordinator in the specified LDSS or the Department's Office of Managed Care at: (518) 486-9015.


Attention
Physicians
Nurse Practitioners
Clinics

Medicaid Coverage of
Human Papillomavirus (HPV) Vaccine
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For claims with dates of service on or after October 13, 2006, New York Medicaid will provide reimbursement for the Human Papillomavirus (HPV) vaccine in accordance with Centers for Disease Control and Prevention (CDC) guidelines.

Guidelines may be accessed at the links provided below:

Billing Medicaid

Woman

  • The procedure code for the vaccine is 90649.
  • Medicaid reimbursement is available when the vaccine is administered to females as young as 9 years and up to and including 26 years. (The vaccine is not available for males at this time.)
  • Beginning November 13, 2006, when provided to Medicaid recipients under the age of 19 years, the vaccine must be obtained from the Vaccines for Children (VFC) program. When billing for VFC supplied vaccines, the procedure code should be appended by the SL modifier and reimbursement for administration of the vaccine will be $17.85.

    Prior to November 13, 2006, reimbursement will be based on the provider's actual acquisition cost, plus a two dollar ($2.00) administration fee.

  • For recipients 19-26 years, reimbursement for the vaccine is the provider's actual acquisition cost for the vaccine, plus a two dollar ($2.00) administration fee.
  • Clinics should refer to the article entitled "Medicaid Reimbursement for Immunizations in Article 28 Hospital-Based and Freestanding Clinic Settings" that appeared in the January 2007 Medicaid Update.

For questions regarding this policy, please contact the Bureau of Policy Development and Agency Relations at:(518) 473-2160.

Questions regarding the VFC Program should be directed to: 1-800-543-7468.

or to the Immunization Program at: (518) 474-4578.


ATTENTION
PHYSICIANS
AND
CLINICS

Issuance of IRS Form 1099
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Computer Sciences Corporation, eMedNY contractor for the Department of Health, issues IRS (Internal Revenue Service) Form 1099 to providers at the beginning of each year for the previous year's Medicaid payments.

The IRS 1099 amount is not based on the date of the checks; rather, it is based on the date the checks were released to providers.

Due to the two-week check lag between the date of the check and the date the check is issued, the IRS 1099 amount will not correspond to the sum of all checks issued for your provider identification number during the calendar year.

Reminder

The IRS 1099 amount is based on check release date.

The IRS 1099 that will be issued for the year 2006 will include the following:

  • Check dated 12/19/05 (Cycle 1478) released on 01/04/2006 through,
  • Check dated 12/11/06 (Cycle 1529) released 12/27/06.

Additionally, in order for group practice providers to direct Medicaid payments to a group identification number and corresponding IRS 1099, providers are reminded that they must submit the group identification number in the appropriate field on the claim (paper or electronic). Claims that do not have the group identification number entered will cause payment to go to the individual provider and his/her IRS 1099.

IRS 1099s for the year 2006 will be mailed no later than January 31, 2007.

The above information is provided to assist providers with reconciling the IRS 1099 amount.Any questions should be directed to the eMedNY Call Center at: (800) 343-9000.


eMedny
Update!

Batch Response File Submissions
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Submitters of transactions need to process the files sent by eMedNY in response to the batch transmissions.

When a file is sent to eMedNY, a series of response files are returned to the submitter to communicate the status of the transaction.

Errors in your transmissions, such as formatting problems or invalid provider identification numbers, may cause transactions not to be processed.

Don't wait until a small check amount or Remittance Advice signals submission problems.

eMedNY sends status files that can prevent surprises and negative impacts on cash flow. Please visit the NYHIPAADESK FAQ section at http://www.emedny.org/hipaa/FAQs/index.html. We have provided a FAQ entitled "What Are The Response Files Sent by eMedNY", which contains all the details.

Questions? Please call the eMedNY Call Center at: 1-800-343-9000.


Important
Information!

National Provider Identifier Implementation Delay
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The New York State Department of Health (DOH) will not be ready to implement the National Provider Identifier (NPI) system changes by the mandated date of May 23, 2007.

Though significant progress is being made towards compliance, DOH feels more time is needed to work with the provider community in creating the necessary crosswalks and to complete the system modifications to ensure no disruption of payments.

There are also external factors influencing this decision, one of which is the inability to access the National Plan/Provider Enumeration System (NPPES) database to populate and validate our crosswalk.

As a result, DOH has implemented an NPI Registration System by which the DOH is requiring the provider community to register their NPI(s) with the corresponding MMIS Provider identification number(s) to create the crosswalk.

Unfortunately, as of December 31, 2006, only 6.03 % of New York's Medicaid providers have registered their NPI(s). To be ready for implementation, 100 percent registration is required before the mandated date.

If you have not registered your NPI, please visit:
www.emedny.org.

To obtain an NPI, please visit:
www.cms.hhs.gov/NationalProvIdentStand.

The new NPI implementation target date is not known at this point. The DOH has asked Computer Sciences Corporation (CSC), NYS Medicaid's fiscal agent, to continuously update the project status in the "Known Issues" list.

The new implementation date will be communicated in a future Medicaid Update article.

DOH requires the MMIS Identification Numbers and/or License Numbers, when applicable, until the NPI compliant system is implemented.

If you utilize a vendor in submitting electronic transactions to New York Medicaid, you should make sure they are aware of this condition.

If you have questions regarding this article, please contact the eMedNY Call Center at: 1-800-343-9000.


SEMINAR SCHEDULE AND REGISTRATION REMINDER
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  • Do you have billing questions?
  • Are you new to Medicaid billing?
  • Would you like to learn more about ePACES?

If you answered YES to any of these questions, please consider registering for a Medicaid seminar. Computer Sciences Corporation (CSC) offers a variety of seminars to providers and their billing staff. Many of the seminars planned for the upcoming months offer detailed information and instruction about Medicaid's web-based billing and transaction program - ePACES. ePACES seminars are designed for specific provider types.

ePACES, is the electronic Provider Assisted Claim Entry System that allows enrolled providers to submit the following type of transactions:

Meeting

  • Claims
  • Eligibility Verifications
  • Utilization Threshold Service Authorizations
  • Claim Status Requests
  • Prior Approval Requests

Professional providers such as physicians, nurse practitioners and private duty nurses can even submit claims in "REAL-TIME" via ePACES. Real-time means that the claim is processed within seconds and professional providers can get the status of a real-time claim, including the associated paid amount, without waiting for the remittance advice to be delivered.

Seminar locations and dates are available at the eMedNY website. Seminar registration is fast and easy and is FREE to enrolled Medicaid providers.

Go to www.emedny.org and select "Training" to find and register for the eMedNY Training Seminar appropriate for your provider category and location. Review the seminar descriptions carefully to identify the seminar appropriate to meet your training needs. Registration confirmation will be sent instantly to your email address.

If you are unable to access the internet to register, you may also request seminar schedule and registration information by contacting CSC's Fax on Demand at (800) 370-5809 -- request document number 1000 for a list of seminars and registration information to be faxed to you. Please contact the eMedNY Call Center at (800) 343-9000 if you have questions about registration.

CSC Regional Representatives look forward to meeting with you at upcoming seminars!


REQUEST FOR SUGGESTIONS FOR FUTURE SEMINARS
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Computer Sciences Corporation (CSC) offers a variety of Medicaid billing seminars throughout New York State.

All seminars are FREE of charge to enrolled Medicaid providers. To view the descriptions and locations of seminars currently offered please visit www.emedny.org and choose the "Training" option from the menu.

Computer

In an effort to better serve the needs of the Medicaid provider community, CSC is seeking input from providers as we plan future seminars for 2007.

  • Perhaps you'd like to attend an ePACES training seminar for a specific provider type.
  • Maybe you'd like to de-mystify the prior approval process or better understand eligibility issues.
  • Do you need assistance getting set up to send and receive electronic claims data?

This is your opportunity to let us know your Medicaid training needs.

Please help us tailor the upcoming seminars to meet your needs.

We strongly encourage you to suggest topics for future Medicaid seminars or make other suggestions regarding seminars by contacting CSC's Provider Services Department via email at:

eMedNYProviderRelations@csc.com

The subject line of your email should be "Seminar Suggestions".

We look forward to hearing from providers and thank you for your continued supportof the New York State Medicaid program!


Providers

Please copy and distribute to your Medicaid clients.

The Bureau of Injury Prevention asks that you....
Keep Young Children Safe in the Car
Use Booster Seats!
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When children outgrow forward-facing child safety seats (usually at 40 pounds), they are too small for adult safety belts (which lay improperly on their necks and over their stomachs). Safety belts that do not fit properly can cause serious injuries - even death if a crash occurs.

Booster seats lower the risk of injury for 4-7 year old children in crashes by 59 percent compared to using only a safety belt. They can be purchased for as little as $20.00!

Why use a booster seat?

A booster seat elevates a child so that the lap and shoulder belt fit properly. The booster seat positions the lap belt over the upper thighs, instead of the stomach, and the shoulder belt across the chest and middle of the shoulder, not touching the neck.

Car Seat

Who should use booster seats?

New York State law requires children ages 4, 5, and 6 to use appropriate child safety restraint systems (which includes child safety seats and booster seats) that meets the child's height and weight recommendations according to the child restraint manufacturer. Generally, children should use belt-positioning booster seats from about age 4 until age 8-10 to be adequately protected.

When is a child ready to use safety belts?

Children are ready to use safety belts without a booster seat when they are tall enough to sit without slouching with their knees bent at the edge of the vehicle's seat. The shoulder belt should rest snugly across the child's chest and shoulder (collar bone), without touching the throat or face. The lap belt should fit low and snug across the child's upper thighs when sitting straight up against the vehicle seat back.

Important Tips

  • Always refer to the booster seat manufacturer's instructions and vehicle owner's manual when using a booster seat.
  • Make sure the booster seat fits your child and vehicle (refer to websites listed).
  • Always use a booster seat with a lap AND shoulder belt, NEVER with the lap belt only.
  • Never allow a child to place the shoulder belt under the arm or behind the back.
  • Children under age 13 should ride in the back seat. It's the safest place to travel.

For more information about the types of booster seats available and child passenger safety, go to

NYS Governor's Traffic Safety Committee
http://www.safeny.ny.gov

NYS Department of Health
http://www.health.state.ny.us/

National Highway Traffic Safety Administration
http://www.boosterseat.gov

American Academy of Pediatrics
http://www.aap.org


Pediatric and Adolescent
Body Mass Index (BMI) Toolkit
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The prevalence of childhood obesity has increased dramatically in the United States and New York over the past three decades. Seventeen percent of US children ages 2 to19 years are obese; in New York State, 22 percent to 24 percent of children are obese.

Unless effective interventions to reduce obesity are developed, children today may live less healthy lives and have a shorter life expectancy than their parents. This is because obesity results in earlier onset and higher rates of:

  • diabetes,
  • cardiovascular disease, and
  • cancer.

Early identification of children at risk for obesity is the first step in prevention. Body Mass Index (BMI) is a composite measure of height and weight, and is the most widely recommended screening tool for classifying weight status in both children and adults.

Girl

The Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics and the American Academy of Family Physicians recommend that BMI should be calculated and plotted at least once a year for all adolescents and children, two years of age and older, as part of routine pediatric health supervision. Because BMI varies by age and sex, it is necessary to use sex-specific BMI-for-age percentiles to screen children for obesity, overweight or underweight.

All children and adolescents who are not in the healthy weight range should undergo further assessment and evaluation to identify underlying causes and to guide management plans.

What's New?

The New York State Department of Health, Bureau of Health Risk Reduction, has just revised their Pediatric and Adolescent BMI Toolkit to be issued on February 15, 2007. It promotes the use of BMI for screening of weight status among children and adolescents. This informational toolkit will be mailed to family physicians, pediatricians, family and pediatric nurse practitioners, WIC nutrition educators and staff at county health departments throughout New York State.

The toolkit is available through the DOH Distribution Center. When ordering indicate the quantity (limit five) and the publication number.

Fax your order to:
(518) 465-0432.

The publication numbers are as follows:

#4950 BMI Wheel,

#4948 Boys BMI-for-age chart,

#4949 Girls BMI-for-age chart, and

#1918 BMI toolkits.

Additional Resources

Information and recommendations for important steps toward the prevention and early identification of childhood overweight and obesity can be found on the CDC's, American Academy of Pediatrics', and the American Academy of Family Physician's websites at:

See also the Department's EPSDT/CTHP Provider Manual for Child Health Plus A (Medicaid) by selecting Provider Manuals at:

http://www.emedny.org

and clicking on the manual section titled:

Assessment of Physical Growth and Nutritional Status


Info

PROVIDER SERVICES
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Missing Issues?
The Medicaid Update, now indexed by subject area, can be accessed online at the New York State Department of Health website: http://www.nyhealth.gov/medicaid/program/update/main.htm
Hard copies can be obtained upon request by emailing: MedicaidUpdate@health.state.ny.us

Do You Suspect Fraud?
If you suspect that a recipient or a provider has engaged in fraudulent activities, please call the fraud hotline at: 1-877-87FRAUD. Your call will remain confidential.

As a Pharmacist, Where Can I Access the List of Medicaid Reimbursable Drugs?
The list of Medicaid reimbursable drugs is available at: http://www.eMedNY.org/info/formfile.html

Patient Eligibility
Call the Touchtone Telephone Verification System (800) 997-1111, (800) 225-3040 or (800) 343-9000.

Address Change?
Questions should be directed to CSC at (800) 343-900, option 5.

Billing Question? Call Computer Sciences Corporation:
Provider Services (800) 343-9000.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at MedicaidUpdate@health.state.ny.us or via telephone at (518) 474-9219 with your concerns.


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_care/medicaid/program/update/main.htm

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