New York State

December 2007  
Volume 23, Number 12  

Medicaid Update

The official newsletter of the New York Medicaid Program

Eliot Spitzer, Governor
State of New York

Richard F. Daines, M.D. Commissioner
New York State Department of Health

Deborah Bachrach, Deputy Commissioner
Office of Health Insurance Programs


Required Information from Ambulette Providers


Annual Ambulette Survey for 2008
Ambulette providers must furnish information to the Office of the Medicaid Inspector General by February 15, 2008.

Information for All Providers

Requesting Individual Provider Training
This article provides instructions for requesting help from a regional representative to resolve billing issues.

Electronic Remittances Will Now Include Paper Claims
Find out how to include additional information on your electronic remittance.

eMedNY Website Monthly Highlight: NYHIPAADESK Frequently Asked Questions
Answers to frequently asked questions regarding the Medicaid Program are available online.

Policy and Billing Guidance

Diagnostic and Treatment Centers: Claiming for Primary Medical Care
A reminder to only perform services listed on the Operating Certificate.

Pharmacy Prior Authorization General Information
How to obtain prior authorization under the Mandatory Generic Drug Program, Preferred Drug Program or the Clinical Drug Review Program.

Correct Billing for Medicare Part B Coinsurance on Non-HIPAA Compliant and Paper Claims
This article contains information on claiming the Medicare coinsurance and deductible.

National Drug Code Required on Medicaid Claims
New requirement on claims for physician-administered drugs.

Medicaid Coverage of Human Papillomavirus Vaccine
How to bill the Medicaid Program for provision of the HPV Vaccine.

2008 Healthcare Common Procedure Coding System
All claims for dates of service on or after January 1, 2008 must incorporate the new HCPCS coding.

Care at Home Case Management Rate Increase
Announcing a new reimbursement rate and billing codes for the Care at Home Waiver program.

General Information

Coinsurance Enhancement for Psychiatrist Services
Announcing a one-time coinsurance enhancement payment to eligible psychiatrists.

Medicaid Wrap-Around Benefit for Dual Eligible Enrollees
Certain drug classes will continue to be included in the wrap-around benefit.

Transitioning to New Medicare Part D Drug Plans: How You Can Help
Medicare enrollees may come to you for advice during this time of transition. Here's how you can help!

Wellpoint/Unicare Change in Point of Sale Facilitated Enrollment Process
Information concerning dual eligibles that are not yet enrolled in a Medicare Part D Prescription Drug Plan.

New York State Medicaid Program Smoking Cessation Policy
Guidance to providers regarding smoking cessation products.

New York State Medicaid Enrollee Stop Smoking Coverage Fact Sheet
Guidance to enrollees regarding Medicaid coverage of smoking cessation products.

Provider Services

The Medicaid Program is dedicated to assuring quality health care to the underprivileged of New York State.

We thank you who treat our enrollees with dignity and respect.

Caduceus


Required Information from Ambulette Providers...........

Annual Ambulette Survey for 2008
Return to Table of Contents

Providers of ambulette services are required to submit vehicle information on an annual basis in accordance with Title 18 of New York Codes, Rules and Regulations (NYCRR) 502.6(b):

Providers who fail to disclose this information are subject to termination from the Medicaid Program.

  • Each provider of ambulette services must, during the month of January of each year, disclose to the Department in writing information concerning those vehicles currently owned or leased by the provider.

  • The information to be disclosed must include at a minimum the name and address of the provider, each vehicle's license number and Department of Transportation identification number and a statement regarding whether the vehicle is owned or leased.

  • If a provider of ambulette services fails to disclose this information, it will constitute an unacceptable practice as defined under 18 NYCRR §515.1 and will result in the imposition of administrative sanctions which may include termination of enrollment as a Medicaid provider.

The Annual Ambulette Survey form available on the next page, or online at:

http://www.omig.state.ny.us/data/images/stories/annual_ambulette_survey_for_2007.pdf

The Annual Ambulette Survey form must be returned by March 17, 2008 to:

New York State Office of the Medicaid Inspector General

Investigations & Enforcement

Attn: 2008 Ambulette Survey

800 North Pearl St, Lower Level

Albany, New York 12204.

Certified/Return Receipt mail is suggested. A copy of the form and proof of mailing should be retained for your records. In the event of non-receipt of the form by the Office of the Medicaid Inspector General, this proof will be used to validate compliance.

Questions? Please call the Office of the Medicaid Inspector General at (518) 408-0692.


2008 Annual Ambulette Survey Form

Date _______________________________________________________________

Provider Name _______________________________________________________

Provider Address ____________________________________________________

Provider Telephone Number ____________________________________________

eMedNY Provider Number ______________________________________________

Name of Person Completing this Form ____________________________________

Title of Person Completing this Form _____________________________________

Signature of Person Completing this Form _________________________________

DAYS OPEN AND HOURS OF OPERATION

SundayMondayTuesdayWednesdayThursdayFridaySaturday
       

 

   Check One  
DMV Plate Number Vehicle Identification Number (VIN) Passenger Capacity OwnedLeased Leased From
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     

NYS DOT OPERATING CERTIFICATE #_________________________________________


Information from All Providers...........

Requesting Individual Provider Training
Return to Table of Contents

Computer

 

Computer Sciences Corporation (CSC) has Regional Representatives available to assist individual providers and to resolve a variety of Medicaid claiming difficulties they may be experiencing. This service is provided free-of-charge to Medicaid enrolled providers.

 

CSC Regional Representatives can help providers with issues/problems such as:

  • Billing problems (paper or electronic).
  • ePACES usage.
  • Prior Approval completion issues.
  • Eligibility verification or service authorization response issues.
  • Remittance interpretation (review solutions for pending and denied claims).

Providers may request to be contacted by a Regional Representative to request an individual training session by calling the eMedNY Call Center at:

(800) 343-9000
or via email at the following address:

emednyproviderrelations@csc

If using the email method to request a call from a Regional Representative, please include your provider identification number, the nature of your request, and contact information. A CSC Regional Representative will contact you either via email or telephone to discuss your needs.

Training Seminars Are Also Available

Fast and easy seminar registration, locations and dates are available online at:

http://www.emedny.org/HIPAA/Provider_Training/Training.html

ePACES seminars are designed for specific provider types. Review the seminar descriptions carefully to identify the seminar appropriate to meet your training needs. Registration confirmation will be instantly sent to your email address.

If you are unable to access the Internet to register, you may also request seminar schedule and registration information through CSC's Fax on Demand system at:

(800) 370-5809;
request document number 1003
for a list of seminars and registration information to be faxed to you.

Questions about registration? Please call the eMedNY Call Center at (800) 343-9000.


Electronic Remittances
Will Now Include Paper Claims
Return to Table of Contents

Providers who signed up for electronic remittances may have noticed that, claims submitted on a paper claim form or State-submitted adjustments were being reported on a separate paper remittance.

World

eMedNY will now include paper claims and state-submitted items on the electronic remittance whenever providers, who only have one ETIN, sign up for electronic remittances. This way their electronic remittance will report all claim activity.

How to Sign Up for Electronic Remittances

To sign up for electronic remittances, providers must have an eXchange or FTP User ID, and submit an Electronic Remittance Request Form.

This Form is located online at:

Complete the form and submit it to:

Computer Sciences Corporation

Attn: Provider Enrollment Support

1 CSC Way

Rensselaer, New York 12144

or FAX: (518) 257-4632.

Questions about electronic remittance options should be directed to the eMedNY Call Center at (800) 343-9000.


eMedNY Website Monthly Highlights

This Month's Highlight:

NYHIPAADESK
FREQUENTLY ASKED QUESTIONS
Return to Table of Contents

At http://www.emedny.org/hipaa/FAQs/index.html you can find out the answers to many frequently asked questions regarding the Medicaid Program.

Check today to find answers to your questions!

Questions? Please call the eMedNY Call Center at (800) 343-9000.


Policy and Billing Guidance...........

Diagnostic and Treatment Centers

Claiming for Primary Medical Care
Return to Table of Contents

Diagnostic and Treatment Centers may only perform services that are specifically authorized by their Operating Certificate.

"Primary Medical Care" includes the following five specialties:

  • Internal Medicine,
  • Family Practice,
  • Pediatrics,
  • Obstetrics/Gynecology, and
  • Dermatology.

Recent audits have revealed that some Diagnostic and Treatment Centers are using a broad interpretation of "Primary Medical Care" to provide services that are not authorized under "Primary Medical Care".

Services that do not fall into the five specialties included under Primary Medical Care, as illustrated in the box at right, must be specifically authorized by the Operating Certificate.

Specialties that require specific approval from the Department of Health are listed in the Certificate of Need Application, Schedule 17C. The Certificate of Need Application is located online at:

http://www.nyhealth.gov/nysdoh/cons/cons_application/page_00_intro_to_con_process.htm

Diagnostic and Treatment Centers that provide services that are not authorized by their Operating Certificate and bill Medicaid for such services are committing an unacceptable practice as defined under Section 515.2 of Title 18 of the Official Compilation of Codes, Rules and Regulations in New York State and will be subject to sanction(s) under Section 515.3.

The Office of the Medicaid Inspector General will seek restitution for unauthorized services billed to the Medicaid Program.

Questions? Please call the Office of the Medicaid Inspector General at (212) 417-5078.


Did you know

The New York State HIV/AIDS Surveillance Annual Report for cases diagnosed through December 2005, is now available online at:

http://nyhealth.gov/diseases/aids/statistics/annual/index.htm


Pharmacy Prior Authorization General Information
Return to Table of Contents

Pharmacy

     

To obtain prior authorization for drugs subject to the Mandatory Generic Drug Program, the Preferred Drug Program or the Clinical Drug Review Program, call the pharmacy prior authorization call center at (877) 309-9493 and follow the appropriate prompts.

  

Prior authorization facts:

 

  • Prior authorization does not guarantee payment. Payment is subject to patient eligibility and other Medicaid guidelines.
  • Prior authorization is required for each new prescription and is effective for the life of the prescription (up to five refills in six months).
  • Prior authorization is not issued to override established requirements of the State Board of Regents, the State Education Department or the State Board of Pharmacy.
  • If a pharmacist has reason to question a prescription, regardless of whether or not it has been prior authorized, they should contact the prescriber.
  • If fraud is suspected, contact the Medicaid Fraud Hotline at:
    1-877-87-FRAUD (1-877-873-7283).
  • Prior authorization cannot be used to obtain:
    • early refills;
    • refills for lost or stolen drugs;
    • extended or vacation supplies; or
    • extension of drug quantity limits.

The current Preferred Drug List is available online at:
https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf

For clinical concerns or preferred drug program questions, please call:
(877) 309-9493.

For pharmacy billing questions, please call:
(800) 343-9000.

For Medicaid pharmacy policy questions, please call:
(518) 486-3209.


Correct Billing for Medicare Part B Coinsurance
on Non-HIPAA Compliant and Paper Claims
Return to Table of Contents

The Medicare Part B deductible for 2008 is $135.

The Part B deductible only needs to be met once in a calendar year.

Some providers are incorrectly billing Medicaid for Medicare coinsurance claims when also billing Medicaid for the Medicare deductible. This has resulted in duplicate claims as well as overpayments.

Policy

The policy for billing Medicare Part B coinsurance and deductible ("crossover") claims is:

  • Medicaid will pay 100% of the Medicare deductible amount and 20% of the coinsurance amount ("20% of the 20%"), for most Part B services. This policy has not changed. (Note: The full coinsurance will be paid if Medicare paid less than the Medicaid Allowed Amount.)
  • A coinsurance claim should only be billed when the patient has exceeded the annual Medicare deductible.
  • The annual deductible is claimed using the "U2" modifier.
    • There should not be any claims using the U2 modifier once the deductible has been met.

Providers are required to report the actual amounts Medicare approved and paid, with the exception of when Medicaid is paying the deductible.

This amount must be included in the Medicare Paid field, along with the amount Medicare actually paid on the claim, to avoid claiming duplicate payment of the deductible!

Submitting a Claim When an Approved Service Exceeds the Deductible

When a portion of the approved service exceeds the deductible claim submitted with a "U2" modifier, the provider should submit a second claim for the coinsurance, as follows:

The Medicare Paid field of the coinsurance claim must include:

  • the amount to be paid by Medicaid on the deductible claim with the "U2" modifier; plus,
  • the amount Medicare paid for this service.
  • Although Medicaid is paying the deductible, this amount needs to be included in the Medicare Paid column, along with the amount Medicare actually paid on the claim, to avoid claiming duplicate payment of the deductible.

Providers are required to report the actual amounts Medicare has approved and paid, except when Medicaid is paying the deductible. When Medicaid is paying the deductible, this amount needs to be included in the Medicare Paid field, along with the amount Medicare actually paid on the claim, to avoid claiming duplicate payment on the deductible.


Correct Billing Example Using 2007 Deductible of $131

To submit a claim for the deductible and coinsurance amount when the 2007 annual Medicare deductible of $131 has not been met, and the Medicare Approved amount for the example provider is $250:

24A. DATE OF SERVICE
MM  DD  YY 
24B. PLACE 24C. PROCEDURE
CD
24D. MOD 24E. MOD 24F. MOD 24G. MOD 24H. DIAGNOSIS
CODE
24I
DAYS OR UNITS
24J. CHARGES 24K. 24L.
 0 9 0 1 0 7      1      1     X   X   X   X   X  U    2              X   X   X . X   X                      1   3  1  . 0  0                    . 0  0               . 
 0 9 0 1 0 7      1      1     X   X   X   X   X                                  .                     2   5   0 . 0  0       2  2  6  .  2  0            . 

In the above example, the balance paid by Medicaid on line 1 for the deductible is $131. The balance paid by Medicaid on line 2 for the coinsurance is $23.80. Note: 20% of the coinsurance amount is paid by Medicaid in most instances, or $4.76 in the example above.

  • Only $131 of the $250 Medicare Approved amount should be on the "U2" claim, as that is the entire remaining deductible for this patient.
  • The second claim for the coinsurance should include the entire $250 Medicare Approved amount for the service in the Medicare Approved field, and the Medicare Paid field should total $226.20.
    • The $226.20 represents the sum of:
      • the amount Medicare Paid ($95.20) plus
      • the deductible amount ($131.00) already claimed to Medicaid using the 'U2' modifier code.

Incorrect Billing Example Using 2007 Deductible of $131

To submit a claim for the deductible and coinsurance amount when the annual Medicare deductible of $131 has not been met and the Medicare Approved amount is $250:

24A. DATE OF SERVICE
MM  DD  YY 
24B. PLACE 24C. PROCEDURE
CD
24D. MOD 24E. MOD 24F. MOD 24G. MOD 24H. DIAGNOSIS
CODE
24I
DAYS OR UNITS
24J. CHARGES 24K. 24L.
 0 9 0 1 0 7      1      1     X   X   X   X   X  U    2              X   X   X . X   X                      1   3  1  . 0  0                    . 0  0               . 
 0 9 0 1 0 7      1      1     X   X   X   X   X                           .                     2   5   0 . 0  0           9  5  .  2  0            . 

This is incorrect because the second claim for the coinsurance (see field 24K in the table above) does not include the Medicare deductible amount already billed with the U2 modifier code. This represents a duplicate claim for the deductible and results in an overpayment of $131.

Failure to include the deductible amount in the Medicare Paid field creates a duplicate claim for the deductible and results in an overpayment.

Questions concerning specific claims and billing procedures should be directed to the eMedNY Call Center at:
(800) 343-9000.

Questions regarding Medicare coinsurance payment policy should be directed to the
Bureau of Policy Development & Coverage at: (518) 473-2160.


Attention

  • Physicians,
  • Nurse Practitioners,
  • Licensed Midwives,
  • Ordered Ambulatory Providers

National Drug Code
Required on Medicaid Claims
Return to Table of Contents

Policy

The National Drug Code is number maintained by the Food and Drug Administration which identifies the drug labeler/vendor, product, and trade package size.

The NDC information is used to maximize federal drug rebates; and can be obtained from the drug invoice and/or packaging information.

Section 6002 of the 2005 federal Deficit Reduction Act (DRA) added provisions requiring ambulatory care providers to report the National Drug Codes (NDC) when billing for physician administered drugs on Medicaid claims.

Effective January 1, 2008, all claims for physician administered drugs, (including drugs administered by nurse practitioners, licensed midwives and drugs administered in an ordered ambulatory setting), submitted on 837 claim formats must include, in addition to the CPT/HCPCS code and units:

  • the 11-digit NDC,
  • the NDC dispensing quantity, and
  • the NDC unit of measure.

Drugs subject to this provision include drugs commonly administered and billed in the ambulatory setting (e.g., chemotherapeutics, therapeutics, etc.). Immunizations are excluded from this requirement.

Electronic claims for physician-administered drugs without valid 11-digit NDC numbers will be rejected effective January 1, 2008. Existing physician administered drug reporting requirements (using the Healthcare Common Procedure Coding System - HCPCS) remain the same. Payment will continue to be based on HCPCS reporting information.

Physician-administered drug claims submitted on paper do not require entry of the NDC information at this time, but will in the future.

Please contact your software vendor regarding this new billing requirement.

=========

NDC Reporting

The Health Insurance Portability and Accountability Act standard code set for NDCs is 11-digits, or a 5-4- 2 configuration. Therefore, when submitting an NDC to the department, a leading zero must be added. Where the zero is added depends upon the configuration of the NDC. Examples of the NDC and leading zero placements follow:

NDC # Configuration
XXXX-XXXX-XX
4 - 4 - 2
Leading Zero Placement for 5-4-2 Configuration
0XXXX-XXXX-XX
5 - 4 - 2
XXXXX-XXX-XX
5 - 3 - 2
XXXXX-0XXX-XX
5 - 4 - 2
XXXXX-XXXX-X
5 - 4 -1
XXXXX-XXXX-0X
5 - 4 - 2

Electronic Billing Instructions

Providers must report the 11-digit NDC and its corresponding information, in addition to the procedure code, in the LIN Segment of LOOP ID 2410 to specify the physician-administered drug that is part of the service described in SV1 for the 837 format. Providers must also report the quantity and unit of measure of the NDC as outlined in the table below:

Reporting NDC Information in 837 Claim Formats
LIN Segment - Drug Identification
e.g., LIN**N4*01234567891
LIN02N4N4 Qualifier identifies NDC being billed.
LIN03 Actual NDC
e.g., 01234 5678 91
Report NDC in the 11-digit format (5-4-2).
Do not use hyphens or spaces.
CTP Segment - Drug Segment
e.g., CTP***2.50*2*UN
CTP03 Unit Price e.g., 2.50
Do not report the dollar sign.
(Enter 0.00 if cost unknown.)
CTP04 Dispensing Quantity e.g., 2
CTP05 Unit of Measure Value Values are:
F2 = International Unit
GR = Gram
ML = Milliliter
UN = Unit

Reporting Multiple NDCs (Including Compound Drugs)

To bill a procedure code with multiple NDCs:

  • Repeat the 2410 Loop up to 25 iterations to report the NDC and its information as instructed above for as many drug components as necessary. The sum of the CTP03 unit price multiplied by the CTP04 Dispensing Quantity should equal the service line charge amount reported in Loop 2400 SV102.

Electronic Remittance Advice (835) and Paper Remittance Advice

The failure to report NDC information will result in the following:

  • Paper Remittance Proprietary Edit Failure 02066.
  • Electronic Remittance Claim Adjustment Reason Code 16 - "Claim/Service lacks information which is needed for adjudication".
  • Remark Code M119 - Missing/Incomplete/invalid/Deactivated/Withdrawn National Drug Code (NDC).

In addition, proprietary edit failure 00561 "Drug/Supply not on File" and 01600 "Discontinued NDC" may appear on paper remittances.

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


The information included in this article previously appeared in the February 2007 Medicaid Update

Medicaid Coverage of Human Papillomavirus Vaccine
Return to Table of Contents

The HPV vaccine is indicated for the prevention of cervical cancer, precancerous or dysplastic lesions, and genital warts caused by HPV Types 6, 11,16, and 18 in females aged 9 to 26 years (the vaccine is not available for males at this time.

The vaccine is given in three injections over a six-month period.

The New York State Medicaid Program provides reimbursement for the Human Papillomavirus (HPV) vaccine in accordance with Centers for Disease Control and Prevention (CDC) guidelines when the vaccine is administered to Medicaid-enrolled females aged 9 to 26 years.

CDC guidelines may be accessed at the links below:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5551a7.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5540-Immunizationa1.htm

Billing the Medicaid Program

  • The procedure code for the HPV vaccine is 90649.
  • When provided to Medicaid enrollees 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.
  • For enrollees aged 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.

Reimbursement for Clinics

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 Coverage at
(518) 473-2160.

Questions regarding the VFC Program should be directed to:
(800) 543-7468 or

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


2008 Healthcare Common Procedure Coding System
Return to Table of Contents

For billing dates of service on and after January 1, 2008, all health care providers and plans must utilize the

Fee-For-Service Providers:

In December 2007, notification on coding changes relating to Medicaid covered services will be available on each Provider Manual homepage at: http://www.emedny.org/providermanuals/index.html.

Check the Provider Communication link or the new Fee Schedule link.

2008 Healthcare Common Procedure Coding System (HCPCS)

as released by the federal Centers for Medicare and Medicaid Services.

Other available coding resources include:

  • HCPCS Level I (CPT-4) procedure codes for practitioners and laboratories can be purchased in hard copy or electronic form through many publishing houses.
  • HCPCS Level II (Alpha-Numeric) codes for other medical services are available in electronic version online at http://www.cms.hhs.gov/HCPCSReleaseCodeSets/
  • ICD-9 Diagnosis and Procedure codes (effective 10/1/2006) are available in electronic version online at http://www.cms.hhs.gov/icd9providerdiagnosticcodes and are also available through publishing houses.

HCPCS and ICD-9 codes are not Medicaid specific. Providers must use the current code set when billing any health care payer.

Questions? Contact the Pre-Payment Review Group at:
(800) 342-3005, Option 4.


Did you know

Weekly influenza activity is reported online. Go to:

http://nyhealth.gov/diseases/communicable/influenza/surveillance.htm


Care at Home Case Management Rate Increase
Return to Table of Contents

The Care at Home (CAH) Medicaid waiver program was initiated in 1985 to enable families to care for children with severe disabilities at home.

The CAH program provides case management, respite, and home and vehicle modification services for children to help them remain in the community with their families. The services are available to children who require nursing home, hospital or intermediate care facility level of care. However, the cost of the child's community based care must not exceed the cost of care provided in a nursing facility or other institution.

New Reimbursement Rate

To better reflect the actual cost of providing these services, effective October 1, 2007, the reimbursement rate for CAH case management services is increased to $20 per quarter hour ($80 per hour). There is no geographic differential rate.

New Billing Codes

For services rendered on or after October 1, 2007, case management providers will use one rate code corresponding to the waiver in which the client is enrolled. (The previous downstate regional differential rate codes have been eliminated.) The rate codes to be used are:

CodeProgramCodeProgram
2301CAH I2311CAH IV
2302CAH II 2317 CAH VI
2305 CAH III

The changes in the rate and rate codes affect the Department of Health programs (CAH I & II) as well as the Office of Mental Retardation and Developmental Disabilities programs (CAH III, IV and VI).

Services provided prior to October 1, 2007 must be billed using the previous regional rate codes and will be paid at the previous regional rate. (Remember, it is the date of service that determines the appropriate rate code, not the date the services are billed.)

New Providers

To qualify as a CAH case management provider, prospective entities must meet qualification standards for Medicaid comprehensive mandatory case management services as well as the CAH case management qualifications.

If you have questions or are interested in becoming a CAH case management provider, please contact the Bureau of Medicaid Long Term Care at:
(518) 486-6562.


General Information...........

Coinsurance Enhancement for Psychiatrist Services
Return to Table of Contents

The 2006-2007 coinsurance enhancement is not a claims adjustment.

This is a one-time payment based upon payments made during state fiscal year 2006-2007.

Basis for Enhancement

The Laws of 2006 provide for a one-time coinsurance enhancement payment to eligible psychiatrists.

This payment is based on coinsurance payments for qualified psychiatric services during the period April 1, 2006 through March 31, 2007.

Enhancement Payment Methodology

Any Medicaid payments made to psychiatrists for Medicare Part B services during this period, made subject to the 20 percent of the coinsurance payments, will be increased in an aggregate amount not to exceed $2,000,000 and will be allocated pursuant to the following methodology:

  • For each psychiatrist who received such payments during the period (April 1, 2006 through March 31, 2007), the Department of Health determined the ratio of each psychiatrist's payments to the total of such payments made during the period, and expressed the ratio as a percentage.
  • For each psychiatrist, the Department of Health multiplied this percentage by $2,000,000.
  • The result of this calculation is the 2006-2007 coinsurance enhancement payment.

We expect these coinsurance enhancement payments will be mailed to eligible psychiatrists by the end of 2007.

Questions? Please contact Johanna Derosby, Division of Financial Planning and Policy, at:
(518) 474-5187.


Do You Have a Question About the Medicaid Program?

Question

Please write to:

Medicaid@health.state.ny.us


Medicaid Wrap-Around Benefit for Dual Eligible Enrollees
Return to Table of Contents

Dual Eligible Enrollees:

Those individuals having both Medicare Part D and Medicaid benefits.

In 2008, the New York State Medicaid Program will continue to provide a "wrap-around" drug benefit for dual eligible enrollees. This benefit is limited to the following drug classes:

  • Atypical anti-psychotics;
  • Antidepressants;
  • Anti-retrovirals used in the treatment of HIV/AIDS; and
  • Anti-rejection drugs used in the treatment of tissue and organ transplants.

Medicare Part D is the primary payor for dual eligible enrollees and should provide access to all medically appropriate medications through the coverage determination and appeal process. It is expected that the Medicaid wrap-around benefit will be used for the four drug classes listed above when:

  • These drugs are not initially covered by the Part D plan;
  • The patient does not meet the plan's utilization management requirements; or
  • There are quantity limits inconsistent with the prescribed amounts.

Providers are expected to work with Part D plans or Medicare Part B to obtain coverage of necessary medications. Medicaid remains the payor of last resort. All Medicaid rules apply to wrap-around benefit claims, including any Medicaid prior authorization requirements and copayment guidelines.

  • Reminder: The Medicaid wrap-around benefit may not be used to obtain early refills, refills for lost or stolen drugs, extended supplies or vacation supplies.

For drugs requiring prior authorization under Medicaid, the prescriber must initiate the prior authorization process for dual eligibles by calling:

(877) 309-9493.

New York Medicaid will continue to pay for the following drugs excluded from the Medicare Part D benefit:

  • barbiturates,
  • benzodiazepines,
  • some prescription vitamins, and
  • some non-prescription drugs.

These drugs may be billed directly to Medicaid.

For billing questions, please call:
(800) 343-9000.

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


Medicare Part D News!

Transitioning to New Medicare Part D Drug Plans
Return to Table of Contents

The Centers for Medicare and Medicaid Services (CMS) has instructed Medicare Part D Drug plans that, in order to prevent a gap in coverage, they must give special attention to those enrollees already stabilized on drugs in the following six classes:

  • antidepressant,
  • antipsychotic,
  • anticonvulsant,
  • anticancer,
  • immunosuppressant, and
  • HIV/AIDS.

Medicare Prescription Drug Plans are required to have an appropriate transition process for the patients that have switched plans or who are experiencing negative changes in formularies.

While each Prescription Drug Plan's transition process may vary, the requirements and expectations are the same for all plans. Specifically, plans must cover at least a 30 day transition supply of medication during the first 90 days of the beneficiary's enrollment. In the long term care setting, plans must cover at least a 31 day supply plus all necessary refills throughout the first 90 days of enrollment.

Prescribers are encouraged to take action to ensure that enrollees will continue with their necessary drug regimen. This may entail switching an enrollee to a covered formulary drug or initiating step therapy, if appropriate, or obtaining an exception authorization through the Prescription Drug Plan.

Pharmacists are encouraged to pay attention to any special messaging they may receive through the claims processing system. Some of these messages may include information regarding the need for prior authorization or the need to take some other action (i.e., calling a plan's hotline to ensure the processing of a transition supply of drug).

The pharmacist must also provide information to the enrollee regarding the exception and appeal process if a drug is not covered by the plan. Pharmacists may be asked by the enrollee to assist them with this process.

Enrollees are encouraged to choose a plan that best meets their needs. Enrollees can receive additional information regarding each Prescription Drug Plan by calling:

 

Medicare:

1-800-MEDICARE

(1-800-633-4227)
OR Health Insurance Information
Counseling Assistance Program (HIICAP):
1-800-701-0501
   or online at the CMS Plan Finder:
http://www.medicare.gov/MPDPF
 

Questions? Please call the Bureau of Pharmacy Policy and Operations at:
(518) 486-3209.


2008 New York State Medicare Part D
Prescription Drug Plans

For people with both Medicare and NYS Medicaid
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The following is a list of the 2008 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 October 2007.

  • Aetna Medicare
  • Aetna Medicare Rx Essentials
  • Customer Service 1-800-213-4599
  • Current Members 1-877-238-6211
  • www.aetnamedicare.com
  • Health Net
  • Health Net Orange Option 1
  • Customer Service 1-800-606-3604
  • Current Members 1-800-806-8811
  • www.healthnet.com
  • RxAmerica
  • Advantage Star Plan by RxAmerica
  • Customer Service 1-866-429-6686
  • Current Members 1-800-429-6686
  • www.meds4medicare.com
  • American Progressive Ins. Co,
  • Prescription Pathway Bronze Plan Reg 3
  • Customer Service 1-800-978-9500
  • Current Members 1-866-566-3052
  • www.rxpathway.com
  • HealthSpring Prescription Drug Plan
  • HealthSpring Prescription Drug Plan
  • Customer Service 1-800-331-6293
  • Current Members 1-800-331-6293
  • www.healthspring.com
  • SilverScript Insurance Company
  • SilverScript
  • Customer Service 1-866-552-6106
  • Current Members 1-866-235-5660
  • www.silverscript.com
  • Bravo Health
  • Bravo Rx
  • Customer Service 1-800-723-9209
  • Current Members 1-877-504-7252
  • www.mybravohealth.com
  • Medco Medicare Prescription Plan
  • Medco Medicare Prescription Plan - Value
  • Customer Service 1-800-758-3605
  • Current Members 1-800-758-4570
  • www.medcomedicare.com
  • Unicare (Anthem)
  • MedicareRX Rewards Value
  • MedicareRX Rewards Standard
  • Customer Service 1-866-892-5334
  • Current Members 1-800-928-6201
  • www.unicare.com
  • CIGNA Healthcare
  • CIGNA Medicare Rx Plan One
  • Customer Service 1-800-735-1459
  • Current Members 1-800-222-6700
  • www.cignamedicarerx.com
  • MemberHealth
  • Community Care Rx Basic
  • Customer Service 1-866-684-5353
  • Current Members 1-866-684-5353
  • www.communitycarerx.com

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

  • First Health Part D
  • First Health Part D - Premier
  • Customer Service 1-800-588-3322
  • Current Members 1-866-823-4701
  • www.firsthealthpartd.com
  • GHI Medicare Prescription Drug Plan
  • GHI Medicare Prescription Drug Plan
  • Customer Service 1-800-325-9792
  • Current Members 1-800-585-5786
  • www.ghi.com
  • Wellcare Health Plans
  • Wellcare Classic
  • Customer Service 1-888-423-5252
  • Current Members 1-888-550-5252
  • www.wellcaredp.com

Questions? Please call the Bureau of Pharmacy Policy and Operations at:
(518) 486-3209.


MEDICARE PART D NEWS!

WellPoint/UniCare
Change In Point of Sale Facilitated
Enrollment Process
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The Point of Sale Facilitated Enrollment (POS FE) process was designed to ensure that qualified individuals with both Medicare and Medicaid (dual eligibles), who are not yet enrolled in a Medicare Part D prescription drug plan, are still able to get services immediately at the pharmacy when a pharmacist believes that an individual has provided the Best Available Evidence of having both Medicare and Medicaid coverage.

Extra Help:

The Social Security Administration offers individuals on Medicare extra help to pay for prescription drugs.

Previously, WellPoint/Unicare, through its contracted pharmacy benefits manager, has reversed claims to pharmacies for beneficiaries who could not be confirmed to be eligible for either Medicaid or extra help by the Center for Medicare Services.

  • Effective August 15, 2007, instead of reversing claims in these circumstances, WellPoint/UniCare began sending a notice directly to these individuals, requesting that they either provide proof of Medicaid eligibility or that they qualify for extra help or reimburse WellPoint/UniCare for the costs of the claim(s). WellPoint/UniCare may still need to reverse other ineligible and/or duplicate claims that have been erroneously paid to pharmacies through the POS FE process.

REMINDER

If your patient receives a letter concerning his or her coverage, he or she should follow the instructions in the letter and forward all requested documentation to the address listed in the letter within 60 days of the date on the notice.

The POS FE process is as follows:

  • Request Patient's Medicare Part D Plan Identification Card.
  • Submit an E1 (eligibility) Transaction to the TrOOP Facilitator.
  • Identify a "Dual Eligible" (Medicare/Medicaid) Individual or Those Eligible for the Low Income Subsidy (LIS) with proof such as:
    • Medicaid Identification Card;
    • Copy of a state document that confirms Medicaid eligibility;
    • Medicare Identification Card; or
    • Low Income Subsidy (LIS) notice from Medicare or Social Security Administration.
  • Bill the POS FE National Plan.

Questions regarding Medicaid pharmacy policy?
Please contact the Bureau of Pharmacy Policy and Operations at:
(518) 486-3209.


New York State Medicaid Program
Smoking Cessation Policy
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No Smoking

  • Smoking cessation therapy consists of prescription and non-prescription agents. Covered agents include nasal sprays, inhalers, Zyban (bupropion), Chantix (varenicline), over-the-counter nicotine patches and gum.
    • Name brand Zyban requires a prior authorization, generic bupropion does not.
    • Prescription nicotine patches are not reimbursable.
  • Two courses of smoking cessation therapy per enrollee, per year are allowed. A course of therapy is defined as no more than a 90-day supply (an original order and two refills, even if less than a 30 day supply is dispensed in any fill).
  • If a course of smoking cessation therapy is interrupted, it will be considered one complete course of therapy. Any subsequent prescriptions would then be considered the second course of therapy.
  • Some smoking cessation therapies may be used together. Professional judgment should be exercised when dispensing multiple smoking cessation products.
  • Duplicative use of any one agent is not allowed (i.e., same drug and same dosage form and same strength).
  • For all smoking cessation products, the enrollee must have an order. A prescription is the terminology for an order of a prescription product. A fiscal order refers to an order, which looks just like a prescription-written on a prescription blank, for an over-the-counter product.

Resources

NYS SMOKERS' QUITLINE (866) NY-QUITS (866-697-8487)
American Cancer Society(800) 227-2345
American Lung Association(800) 586-4872
Centers for Disease Control and Prevention(800) CDC-4636 (800-232-4636)
National Cancer Institute(800) 4-CANCER (800-422-6237)

For more information on the New York State Medicaid Smoking Cessation policy, please call the Bureau of Pharmacy Policy and Operations at:
(518) 486-3209.


New York State Medicaid Enrollee
Stop Smoking Coverage Fact Sheet
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Policy

No Smoking

  • Stop smoking products can be obtained with a prescription. Medicaid will pay for inhalers, nasal sprays, Zyban (bupropion), Chantix (varenicline), over-the-counter nicotine patches and gum.
  • Your health care provider must write a prescription for you to receive either a prescription or over-the counter stop smoking product.
  • You are allowed a course of stop smoking therapy twice a year. A course of therapy is defined as no more than a 90 day supply (an original order and two refills, even if less than a 30 day supply is dispensed in any fill).
  • Some smoking cessation therapies may be used together. For example, Zyban, taken by mouth, and nicotine patches, which are applied to the skin, may be used at the same time. Ask your physician and pharmacist what is appropriate for you.

Resources

There are many cost-free programs and resources available to help you quit and stay tobacco free. Some are listed below.

RESOURCES

Local cessation support program
information can be obtained from:
The New York State Smokers' Quitline
Toll-free:
(866) 697-8487


American Cancer Society
Toll-free number:
(800) ACS-2345
(800)-227-2345

American Lung Association
Toll-free number:
(800) 586-4872
BROCHURES AND OTHER INFORMATION

Centers for Disease Control & Prevention
Toll-free number:
(800) CDC-4636
(800-232-4636)

National Cancer Institute
Toll-free number:
(800) 4-CANCER
(800) 422-6237

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/health_care/medicaid/program/update/main.htm

Hard copies can be obtained upon request by emailing: medicaidupdate@health.state.ny.us

Questions about an Article?
For your convenience each article contains a contact number for further information, questions or comments.

Questions about billing and performing EMEVS transactions?
Please contact CSC Provider Services at: (800) 343-9000.

Provider Training
To sign up for a provider seminar in your area, please enroll online at:

http://www.emedny.org/training/index.aspx

For individual training requests, call (800) 343-9000 or email:

emednyproviderrelations@csc.com

Enrollee Eligibility
Call the Touchtone Telephone Verification System at any of the numbers below:

(800) 997-1111    (800) 225-3040      (800) 394-1234.

Address Change?
Questions should be directed to CSC at: (800) 343-9000.

Fee-for-service Provider Enrollment
A change of address form is available at:

http://www.emedny.org/info/ProviderEnrollment/index.html

Rate-based/Institutional Provider Enrollment
A change of address form is available at:

http://www.emedny.org/info/ProviderEnrollment/index.html

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon, at: medicaidupdate@health.state.ny.us

Medicaid Update is a monthly publication of the New York State Department of Health containing information regarding the care of those enrolled in the Medicaid Program.

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