February 2008  
Volume 24, Number 2  

New York State

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



Information for All Providers

Adjusting Previously Paid Claims with Multiple Claim Lines
If you need to adjust (replace) previously paid claims, read this article for instructions.

Claims Pending Review for Edits 00127 and 01283
If you see these edits, read this article to find out what they mean.

Policy and Billing Guidance

Article 28 Clinics and Practitioners: Clarification of Commercial Insurance Billing Requirements
This article provides billing guidance and information regarding Medicaid enrollees with commercial insurance coverage.

Preferred Drug Program Update
Contains the updated Preferred Drug List, with changes effective February 21, 2008.

Enhanced Coverage for Family Planning Benefit Program Enrollees
Clinics, medical practitioners and laboratories should review this article for billing guidelines and additional information related to the Family Planning Benefit Program.

New Site Edits for Dental Prior Approval
Carefully review this article for new requirements effective April 1, 2008.

Durable Medical Equipment Update
Announcing changes to HCPCS coding, wheeled mobility, labor and fees; as well as a new process for commonly requested miscellaneous equipment.

Pharmacy and DME Providers: Supplies Update.
Certain procedure codes have been discontinued effective January 1, 2008.

General Information

Bridges to Health Medicaid Waiver Program for Children in Foster Care
Announcing a new program available January 1, 2008.

Family Health Plus Premium Assistance Program
Announcing a new program for those eligible for Family Health Plus benefits.

Medicare Drug Coverage Under Part A, Part B and Part D
A desk guide for pharmacists and prescribers.

National Guidelines for Coronary Angiography
The general outcome of a recent review and national guidelines for patient management.

Provider Services

Caduceus


Do you suspect that an enrollee or a provider has engaged in fraudulent activities?
Return to Table of Contents

Please call:

1-877-87FRAUD

Your call will remain confidential.

Or complete a Complaint Form available at:

www.omig.state.ny.us


Information for All Providers...........

Adjusting Previously Paid Claims With Multiple Claim Lines
Return to Table of Contents

Document level processing bundles multiple lines submitted on a claim and pays at the claim level assigning the same transaction control number (TCN) to each line. When the TCN is used to submit an adjusted claim, all lines that were assigned that TCN will be impacted by the transaction.

Document level processing impacts both electronic and paper claims submitted with multiple claim lines by fee-for-service providers as well as rate-based home health and clinic providers.

To adjust (replace) a previously paid claim, providers must know what lines were originally paid under the TCN.

Providers are responsible to correctly resubmit all claims that may be voided as a result of improperly adjusting previously paid claims

Take Note:

  • If an adjustment is submitted without one or more of the lines paid from the previous claim, those omitted lines will be voided and the money taken from the check issued for the weekly payment cycle in which the void is processed.
  • If the amount of the voided claims exceeds the total paid claims for that cycle, a negative balance is placed on the provider's file and the payment for any subsequent claims will be used to reduce the negative balance to zero before any further checks will be issued.
  • Submitting multiple adjustments without understanding document-level processing can result in unintended voided claims that may create a negative balance for the provider.

Suggestions

Fee-for-service providers are urged to familiarize themselves with the instructions and examples in the Billing Guidelines section of their provider manual before submitting claim adjustments.

Providers who have a large number of adjustments to submit may want to initially submit only one claim to ensure the adjustment processes as the provider intended.

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


Claims Pending Review for Edits 00127 and 01283
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Claims failing eMedNY edits 00127 (Medicare Paid Amount Reported Less Than Reasonable Amount), and 01283 (Upper Dollar Limit Exceeded) will pend for review prior to final adjudication. The status of electronic claims pended for these edits are located on the provider's Supplemental Remittance file, sent with the HIPAA-compliant (835) remittance.

If the claim(s) is denied upon final adjudication, the corresponding HIPAA codes that will be reported on the 835:

  • 00127: Adjustment Reason Code 16 and Remittance Remark Code MA92
  • 01283: Adjustment Reason Code A1 and Remittance Remark Code N14.

If the claim(s) is pended, the corresponding claim status (277 or via ePACES) codes are:

  • Category Code: P2 Pending/In Review - The claim/encounter is suspended pending review.
  • 00127: Claim status code 182.
  • 01283: Claim status code 9.

If you have claims pended for the above edits and you can provide documentation (i.e., Medicare Explanation of Medical Benefits (EOMB)) to support that your billing was appropriate, please follow these instructions:

Documentation should be sent to the Edit Review Panel for these edits ONLY.

Documentation sent for any other edits will be returned to the provider.

  1. If you receive a paper remittance from Medicaid, and would like Computer Sciences Corporation (CSC) to review the claim, circle the Transaction Control Number (TCN) of the claim(s) pending for edit 00127 or 01283.
    If you receive an electronic remittance from Medicaid, you must indicate the TCN of the Medicaid claim on the Medicare EOMB.
  2. On the Medicare EOMB, circle the information corresponding to the claim(s) to be reviewed.
  3. Mail the documentation to the following address:

    Computer Sciences Corporation
    Attn: Edit Review Panel
    P.O. Box 4604
    Rensselaer, NY 12144-4604.

    Documentation that is incomplete, illegible or unusable will be returned to the provider. CSC staff will review the documentation and adjudicate the claim(s) accordingly through the regular claim processing system. The adjudicated claims will appear on the provider remittance statement.

Providers making inquiries or requesting billing training by Regional Representatives should contact CSC by calling the eMedNY Call Center at:

(800) 343-9000 or

via email to eMedNYProviderRelations@csc.com


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

Attention
Article 28 Clinics and Practitioners

Clarification of Commercial Insurance Billing Requirements
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Medicaid regulations at 18 NYCRR § 540.6(e)(6) require a provider to pursue any available commercial insurance prior to submitting a claim to Medicaid. This means that providers must bill available commercial insurance, but are not required to contract with all available commercial insurers.

The Patient Responsibility Amount is the Amount for which the patient would be responsible if he or she did not have additional insurance.

This amount varies depending on whether or not the provider contracts with a commercial insurance payer.

Until February 1, 2007, the Medicaid Program paid the difference between the commercial insurance payment amount and the Medicaid rate or fee.

Effective February 1, 2007, Medicaid pays the lower of either:

  • the Medicaid rate minus the insurance payment, or
  • the Patient Responsibility Amount.

When a provider contracts with a commercial insurance payer, the Medicaid Program pays the difference between the commercial insurance payment amount and the commercial insurance patient coverage amount. Essentially, Medicaid pays the commercial insurance co-payment, deductible and/or co-insurance.

When a provider does not contract with a commercial insurance payer, Medicaid pays the patient responsibility. In this case, this is the difference between the commercial insurance payment amount and the provider's usual and customary charge, up to the Medicaid rate.

Background Information

All Medicaid payments are subject to federal and State Medicaid subrogation rules. This means that the Medicaid Program "stands in the shoes of the enrollee" with regard to that commercial insurance policy, and is entitled to receive the value of those policy benefits either directly or through a reduction in the amount otherwise payable to the provider.

The Centers for Medicare and Medicaid Services has specifically instructed State Medicaid agencies to limit payments in these circumstances, per Section 3904.7 of the State Medicaid Manual:

"...The provider's agreement to accept payment of less than its charges constitutes receipt of a full payment for its services, and the insured has no further responsibility. Medicaid is intended to make payment only where there is a recipient legal obligation to pay..."

Where the enrollee is obligated to pay the provider a co-payment (that is, the Patient Responsibility Amount), the federal subrogation requirements obligate Medicaid to pay that amount to the extent that total payment to the provider does not exceed the Medicaid payment amount.

Example of Situation

Payment TypeOld Pricing MethodNew Pricing Method with ContractNew Pricing Method without Contract
Usual & Customary Charge$250$250$250
Medicaid Clinic Rate$100$100$100
Commercial Insurance Payment$60$60$60
Commercial Insurance Co-pay$10$10Co-pay not applicable
Commercial Insurance Coverage Amount $70$70$60
Patient Responsibility$10$10$190
Amount Medicaid Pays$40
(Medicaid rate minus Insurance Payment)
$10
(Lower of: Medicaid rate minus Insurance Payment or the reported Patient Responsibility)
$40
(Lower of: Medicaid rate minus Insurance Payment or the reported Patient Responsibility)
Total amount Provider is paid for the service$100$70$100

Note: If the Medicaid payment is lower than the commercial insurance payment, Medicaid pays nothing. This policy is unchanged.

Billing Guidance

If a clinic provider has received reduced payments, but is not contracting with a commercial insurance payer, the clinic should enter the difference between the commercial insurance payment and its usual charge in the patient responsibility field on the claim form.

If using 837I, 837D or 837P claim formats, the difference between the commercial insurance payment and the clinics usual charge should be represented in:

  • Loop 2320 CAS segment using "PR" for Patient Responsibility in CAS01; and
  • Claim Adjustment Reason Code "38" - Services not provided or authorized by designated (network/primary care) providers in CAS02.

Reduced payment rates for clinics that do contract with commercial insurance providers are correct.

For questions regarding appropriate billing procedures, please call Robert Pozniak at (518) 257-4511.
For questions regarding Third Party policy issues, please call (518) 474-9193.


Update

Preferred Drug Program Update
Return to Table of Contents

 

Effective February 21, 2008, prior authorization requirements will change for some drugs in the following nine drug classes:

Antihistamines - Second Generation

Beta2 Adrenergic Agents - Inhaled Short Acting

Beta2 Adrenergic Agents - Inhaled Long Acting

Cephalosporins - Third Generation

Corticosteroids - Inhaled

Anti-Emetics

Anti-Fungals

Anti-Virals

Fluoroquinolones- Otic

To obtain prior authorization for non-preferred drugs, call the clinical call center at:

(877) 309-9493

and follow the appropriate prompts.

Reminder:

Preferred drugs do not require prior authorization!

 

The New York State Medicaid Preferred Drug List is available at the following website: https://newyork.fhsc.com/

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

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

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


Attention
Clinics, Medical Practitioners & Laboratories

Enhanced Coverage for Family Planning Benefit Program Enrollees
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The Centers for Medicare and Medicaid Services has approved coverage of additional procedures and services performed during a family planning visit as well as follow-up procedures and treatment for "limited medical conditions" diagnosed during a family planning visit. Additionally, New York State has authorized coverage of the follow-up treatment of specific sexually transmitted infections (STIs).

Claims for these services and procedures may be submitted on or after March 27, 2008, for service dates retroactive to July 1, 2007.

Additional Services Performed During a Family Planning Visit

To bill for these services, claims must contain:

  • A "Y" in the Family Planning Box.
  • A primary ICD-9CM diagnosis code in the V25 series.
  • The appropriate CPT-4 code for the procedure(s) or medical supply (Table A).
  • The appropriate CPT-4 evaluation and management visit code, initial visit (Table D), or follow-up visit (Table E).
  • Clinic claims must also include the clinic rate code.

Follow-up Procedures and Treatment for Limited Medical Conditions Diagnosed During a Family Planning Visit

To bill for these services, claims must contain:

  • A primary or secondary ICD-9CM diagnosis code in the V25 series.
  • The appropriate CPT-4 procedure code(s) performed from the approved follow-up procedures (Table B).
  • The appropriate CPT-4 evaluation and management follow-up visit code (Table E).
  • Clinic claims must also include a clinic rate code.

Follow-up Treatment of Sexually Transmitted Infections

To bill for these services, claims must contain:

  1. If the primary reason for the follow-up visit is for treatment of a STI, the primary ICD-9 CM diagnosis code must be the STI (Table C).
  2. If the primary reason for the follow-up visit is for family planning and STI treatment is secondary, the primary ICD-9CM diagnosis code must be in the V25 series and the secondary diagnosis code must be the specific STI (Table C).
  3. A CPT-4 procedure code for an evaluation and management follow-up visit (Table E).
  4. Clinic claims must also include a clinic rate code.

Questions? Please call the Bureau of Policy Development and Coverage at (518) 473-2160.

 

Table A
Additional CMS-Approved CPT-4 Codes for the FPBP
58100770818224782948850028537886901874868817399386
58340770838227082950850048557687015874958830299394
71020800488255082951850078561087040876208830599395
74000800538255383001850188565187075876218830799396
768308006182565830028502785652870778779793307A4931
768568007682570836908503285730870888780199384J7306
768578101582575840758504586580871648789999385J7307
7707882040826708414485049866328716688143  
7707982043826778414685210866878720688152  
7708082150829478444385300869008725588161  

Notes:

J7307 is the new CPT code for Implanon, and replaces code S0180, effective January 1, 2008.

The CPT-4 procedure codes above are in addition to the family planning codes published in the May 2007 Medicaid Update found at:

http://www.nyhealth.gov/health_care/medicaid/program/update/main.htm

Table B
CPT-4 Procedure Codes for Follow-Up Treatment of Limited Medical Conditions
10060114214692454056540655644056820574205745457460 57510
10140469005405054057564055650156821574215745557461 57511
11420469225405554060564205670057061574525745657505 J0696

 

Table C
ICD-9 CM Diagnosis Codes for Sexually Transmitted Infections
054.10-054.12054.40-054.1054.71-054.74054.8-054.9078.19079.4
054.13054.43-054.44054.79077.0078.88131.0-131.9
054.19054.49090-099.9077.98079.88 
054.2-054.3054.6078.1078.11079.98 

 

Table D
CPT-4 Procedure Codes for Evaluation and Management Initial Visits
992019920299203992049920599241
992429924399244992459938499385
99386     

 

Table E
CPT-4 Procedure Codes for Evaluation and Management Follow-Up Visits
99211992139921599242992449939499396
992129921499241992439924599395 

 


New Site Edits for Dental Prior Approval
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Beginning April 1, 2008, enhanced editing of site information associated with procedure codes on dental prior approval requests will be implemented.

Only those procedures which require site information should have the site information included.

If site information is included when it is not required, the request will be rejected from further processing until receipt of an appropriate correction.

Procedures requiring site information are identifiable in the Dental Fee Schedule by the parenthesis after the procedure code.

Questions can be directed to the Pre-Payment Review Group at (800) 342-3005, Option # 2.


Did you know

 

You can find recall information regarding toys, clothing and other children's products online at:

http://www.nyhealth.gov/environmental/children/recalls.htm


Question

Do You Have a Question About the Medicaid Program?

  

Please write to:

Medicaid@health.state.ny.us


Wheelchair

Durable Medical Equipment Update
Return to Table of Contents

Please note the following changes relating to HCPCS coding, Wheeled Mobility and Labor fees and a new process for some commonly requested miscellaneous equipment.

HCPCS Changes

Effective for order dates on and after January 1, 2008, the following code has been discontinued:

E2618 #Wheelchair accessory, solid seat support base (replaces sling seat), for use with manual wheelchair or lightweight power wheelchair, includes any type mounting hardware.

For a manual wheelchair:

  • If a new folding wheelchair is being delivered use code E0992.
  • If a replacement is needed, use E0992, with "RP" modifier.
  • A solid seat support base is included with the payment for a rigid manual wheelchair; no additional payment will be made.

For pediatric seating:

  • A solid seat support base is included with the payment for planar and contoured pediatric seating codes E2292 and E2294: no additional payment will be made.
  • If a replacement solid seat support base is needed, use the wheelchair code with the RP modifier.

For a power wheelchair:

  • A solid seat support base is included with the payment for a new wheelchair: no additional payment will be made.
  • If a replacement solid seat support base is needed, use wheelchair code with the -RP modifier.

Fee Schedule Updates

  • Effective for dates of service on and after January 1, 2008 the fee for E1161 #Manual adult size wheelchair, includes tilt in space is $2287.24. The fee includes any transport option.
  • Effective for dates of service on and after January 1, 2008 the fee for E0992 #Manual wheelchair accessory, solid seat insert will be $112.28. The code describes a solid seat support base and the fee includes any type mounting hardware.

New Process for Commonly Requested Miscellaneous Items

Effective for order dates on and after January 1, 2008, a new process is established for commonly requested items categorized as E1399 Durable medical equipment, miscellaneous.

A UESS is covered when the medical need for positioning in a wheelchair cannot be met with less costly alternatives such as any combination of a safety belt, pelvic strap, harness, prompts, armrest modifications, recline, tilt in space or other existing or potential seating or wheelchair features.

Upper Extremity Support System & Rolling Recline Shower Commode Chair

An upper extremity support system (UESS) and rolling recline shower commode chair will not be subject to medical review and will have maximum reimbursable amounts (MRA) assigned to them.

Documentation should include the patient's ability to effect knowing and purposeful position changes using the UESS.

UESS dimensions should not exceed the positioning length of the forearms (e.g., 12-15"). A UESS featuring enhancements (i.e. rims, lips, padding) or dimensions greater than medically needed for upper extremity support alone will not be approved.

A wheelchair tray is not considered a seating tray and will not be approved for completion of activities of daily living. The MRA for a UESS, any type, includes all modifications, padding and mounting hardware is $199.88.

A rolling recline shower commode chair is covered when recline is necessary to complete hygiene needs and the patient either has positioning needs that cannot be met by upright and fixed angle chair or the patient's postural control requires recline feature.

The MRA for a rolling recline shower commode chair, any size, including safety belt and padded headrest with any type armrest is $390.45.

A medically justified foot rest may be billed separately using code E0175 #Foot rest, for use with commode chair, each (one or two piece).

E1399 will be used for the UESS and rolling recline shower commode chair to obtain a prior approval number without submission of medical documentation using the following procedure:

  1. DME provider obtains valid order and medical documentation (to maintain in their records for audit purposes) from the ordering practitioner;
  2. DME provider submits a prior approval request containing a copy of the valid order and either a manufacturer's price quote or the item's make and model;
  3. These items must be submitted singularly on a separate prior approval from all other prior approval items;
  4. The DME provider will be issued a prior approval priced up to the established MRA and may bill Medicaid upon dispensing.

Reviewers will contact a requesting DME provider and ordering practitioner for clarification if same or similar items have recently been provided and/or currently being requested by another provider.

Labor and Repairs

Effective for dates of service on and after January 1, 2008, the fee for E1340 #Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes, L4205 Repair of orthotic device, labor component, per 15 minutes and L7520 Repair of prosthetic device, per 15 minutes (includes evaluation) will be $10.00.

More than two hours of repair requires prior approval.

News

Billing instructions:

  • E1340 is reported when:
    1. No specific code exists to describe the item in need of service, and
    2. The charge for replacement parts and related labor exceeds the fee for A9900.
  • The -RP (Repair and replacement) modifier should be reported when a specific code and fee is listed in the DME Provider Manual for the item requiring service.
  • E1340 must not be billed in conjunction with the specific code plus -RP for repair and replacement of the same item. For listed codes, the labor component of repair and replacement is included in the payment resulting from use of the specific listed code with the -RP.
  • Labor is included in the payment for new equipment and components. E1340 and -RP must not be billed in conjunction with new equipment or components. The only exception is when over two hours of labor is required for a skilled technician to perform complex disassembly and assembly to add a new component to existing equipment dispensed previously.
  • Repairs and replacement covered under the manufacturer's warranty are not to be billed.
  • When repair and replacement is performed by a manufacturer, Medicaid pays the Medicaid provider the line item labor cost on the manufacturer's invoice and the applicable Medicaid fee on the parts. If labor and parts charges are not separately itemized on the invoice as required by 18NYCRR 505.5, the Medicaid provider is not entitled to a markup on the cost of parts and will only be paid the manufacturer invoice cost of parts and labor.
  • See Rule 12 in the DME Provider Manual, Procedure Codes Section, for further information on repair and labor.

Questions? Call the Pre-Payment Review Group at (800) 342-3005.


Attention
Pharmacy and DME Providers

Effective for dates of service on and after January 1, 2008 refer to the cross-reference procedure code for billing a standard gastrostomy tube. Do not bill B4086 for dates of service after December 31, 2007.

Effective with order dates on and after January 1, 2008, use B4088 for a low-profile gastrostomy tube. Prior approvals granted with order dates prior to January 1, 2008 under T5999 for low-profile gastrostomy tubes will be honored for the approved period of service, after which B4088 should be reported.

Discontinued CodesCross-Reference Procedure CodePrice
B4086#B4087 #Gastrostomy/jejunostomy tube, standard, any material, any type, each $ 22.89
(With the addition of B4088, the low profile tube no longer is billed using T5999, which continues to be active for other supply items.)B4088 #Gastrostomy/jejunostomy tube, low-profile, any material, any type, each (for patients who cannot tolerate the size of a standard gastrostomy tube or who have experienced failure of a standard gastrostomy tube.

This code is for replacement in the patient's home and should not be billed when the tube is replaced in the physician's office, ER or facility with an all inclusive rate This kit includes tube/ button/ port, syringes, all extensions and/or decompression tubing and obturator if indicated).

# = DVS AUTHORIZATION REQUIRED
$134.58

Effective for dates of service on and after January 1, 2008 the allowable monthly quantity on this code will increase from 100 to 200 units per month:

CodeDescriptionQuantity/SizePrice
A4221#Supplies for maintenance of drug infusion catheter, per week (list drug separately) (BILL MONTHLY)

#=DVS AUTHORIZATION REQUIRED
up to 200 units per month$1.00

A4221 is used for all supplies necessary for maintenance of drug infusion catheters and external pumps and/or supplies necessary for the administration of drugs (except insulin) not otherwise listed in the Pharmacy Provider Manual. Prior approval is required only when the total charge for supplies not otherwise listed exceeds $200.00 (200 units) per month.

Questions? Call the Pre-Payment Review Group at (800) 342-3005.


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

Bridges to Health Medicaid Waiver Program
For Children in Foster Care
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The New York State Department of Health (DOH) and Office of Children and Family Services (OCFS) announce "Bridges to Health" (B2H), a new Medicaid program for children in foster care under age 21.

Program Information

B2H became effective January 1, 2008, and will provide community based services to children who:

  • are in the care and custody of a county department of social services (LDSS) or OCFS;
  • have significant mental health care needs, developmental disabilities or medical fragility; and
  • require an institutional level of care.

OCFS will operate the program through LDSS offices statewide while DOH has overall responsibility for oversight of the program. B2H program information is available online at:

http://ocfs.state.ny.us/main/B2H   or    http://www.emedny.org/ProviderManuals/B2H/index.html

B2H will be phased in over a three year period. A total 3,305 participant slots will be distributed between now and 2010:

Children discharged from foster care may remain in the B2H program if they are otherwise eligible for Medicaid based upon a household of one and the child's own income and resources.

  • 2,688 serious emotional disturbance;
  • 541 developmentally disabled; and
  • 76 slots medically fragile.

Covered Services

The list of services below will be available to participants in each waiver:

  • Accessibility modifications;
  • Adaptive and assistive equipment;
  • Crisis respite;
  • Crisis avoidance, management and training;
  • Day habilitation;
  • Family caregiver supports and services;
  • Health Care integration;
  • Immediate crisis response services;
  • Intensive in-home supports;
  • Planned respite;
  • Prevocational services;
  • Skill building;
  • Special needs community advocacy and support; and
  • Supported employment.

For more information, please call:

Mimi Weber, Office of Children and Family Services (518) 408-4064; or

Priscilla Smith, Department of Health (518) 486-6562.


FHP

Family Health Plus
Premium Assistance Program
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Persons eligible for Family Health Plus who have access to cost effective health insurance through their employer are now eligible for premium assistance through the

Family Health Plus Premium Assistance Program.

When a person enrolls in the Premium Assistance Program, the State will pay or reimburse:

  • the employee's share of the insurance premium;
  • the employee's deductible, coinsurance and any co-payment amounts that exceed those currently required by Family Health Plus for persons eligible and enrolled in the program; and
  • services covered by Family Health Plus but not covered by the employer's plan (subject to the requirements below).

Individuals without access to employer-sponsored health insurance are not impacted by this change in eligibility rules.

Program Eligibility Review

Individuals with access to employer-sponsored health insurance will be asked to provide information about the available coverage to their local social services district (in New York City, the Human Resources Administration).

If the local social services district determines that the employer-sponsored health insurance is qualified and cost effective, the individual will be required to join the employer-sponsored health plan at the earliest opportunity.

Payment for Services Not Covered by the Employer-Sponsored Health Plan

Enrolled individuals will receive a Medical Assistance Benefit Card which they may use to obtain Family Health Plus benefits not covered by their employer-sponsored health insurance from any enrolled Medicaid provider on a fee-for-service basis. Medicaid providers must verify eligibility prior to provision of these services.

The Medicaid Eligibility Verification System (MEVS) response for these enrollees will be "Other" or "Additional Payer". The commercial policy number, plan code and plan address will also be provided. For additional information please refer to your MEVS Provider Manual located at:

http://www.emedny.org/ProviderManuals/index.html

Current procedures for billing commercial insurance as primary and Medicaid as secondary remain applicable.

Questions? Please call the Third Party Policy Unit at (518) 474-9193.


Medicare Drug Coverage Under Part A, Part B and Part D
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The following table, developed by the National Medicare Training Program, is designed to help you determine which part of Medicare covers a drug in a particular situation, assuming all other requirements are met, e.g., a drug must still be medically necessary to be covered. It provides general guidance only and does not cover all possible situations.

Type of CoverageCare Setting*Drug TypeCovered By**Comments
Original Medicare and a Medicare Prescription Drug Plan (PDP)Hospital (inpatient) or skilled nursing facility AnyPart A Part A coverage is subject to certain limits; drugs may be covered by Part B or Part D for stays not covered by Part A
Doctor's OfficeVaccines; pneumococcal pneumonia, influenza, and (for intermediate - to high-risk people) Hepatitis B; and some other vaccines related to injury or illnessPart B 
All other vaccinesPart D
Injectable/IV drugs given by a doctor and not usually self-administeredPart BEligible for Part D coverage if purchased at a pharmacy and administered by a doctor
HomeDrugs that must be administered by Medicare-covered durable medical equipment, e.g., nebulizer or infusion pumpPart B 
Long Term Care (LTC)Drugs that must be administered by Medicare-covered durable medical equipment, e.g., nebulizer or infusion pumpPart D
Home or LTCInsulin and injection supplies (syringes, needles, alcohol swabs, and gauze)Part DBlood glucose testing supplies covered by Part B (DME)
Immunosuppressive drugs for a person who received a Medicare-covered transplant.Part BEligible for Part D coverage for other situations.
Some oral anti-cancer drugsPart B for cancer treatmentEligible for Part D coverage for other uses
Some oral anti-ematic drugs used within 48 hours of chemotherapyPart BEligible for Part D for other situations
Erythropoietin (EPO) for anemia in people with chronic renal failure who are undergoing dialysisPart BEligible for Part D coverage for other situations
Parenteral nutrition (tube feeding) for permanent dysfunction of digestive tractPart BCovered by Part D for other situations
Medicare Advantage Plan with drug coverageAnyAnyPlan provides all Part A, Part B, and Part D-covered services, including prescription drugs
Original Medicare or Medicare Advantage Plan AND elected hospice careAnyDrugs for symptom control or pain reliefPart A 
Drugs intended to cure terminal illness Not covered by Medicare A person can stop hospice care and go back to his or her previous Medicare coverage at any time 
For a condition unrelated to the terminal illness (e.g., a non-related infection)Same as for non-hospice care
Original Medicare with PDP or Medicare Advantage Plan AND MedicaidHome or LTCDrugs excluded by law from Part DNot covered by Medicare 
Hospital or skilled nursing facilityDrugs excluded by law from Part DPart APart A coverage is subject to certain limits; drugs may be covered by Part B or Part D for stays not covered by Part A

* Long-term care facilities include skilled nursing facilities (for stays not covered by Medicare), nursing homes and institutions which give skilled care. Generally "home" care setting includes Medicare-covered home health care, and "doctor's office" care includes hospital outpatient care.

** Drugs are covered under Part D to the extent they are included on the formulary for the person's plan. If a person's drug is not covered, he or she can ask the plan for a coverage determination, but may have to pay full price for that drug. For more information, see "Your Guide to Medicare Prescription Drug Coverage," CMS publication Number 11109, at http://www.medicare.gov/Publications/Pubs/pdf/11109.pdf


National Guidelines for Coronary Angiography
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Working with the Office of Health Systems Management, the Medicaid Program has analyzed diagnostic cardiac catheterization procedures at hospitals throughout New York State. A wide variation among hospitals with respect to the percentage of Medicaid patients who are found to have normal coronary arteries after a diagnostic cardiac catherization procedure was noted.

To ensure that Medicaid patients are receiving high quality care in accordance with national guidelines for evidence-based best practices, the Department of Health will be exploring the extent to which this wide practice variation represents case mix differences or potential overuse or misuse of diagnostic cardiac catheterization. Chart reviews by peer reviewers will be conducted on selected cases.

Additionally, we call your attention to the following national guidelines from the American College of Cardiology and the American Heart Association for management of patients with chronic stable angina and asymptomatic patients with known or suspected coronary artery disease. The guidelines are available on the American College of Cardiology and American Heart Association Web Sites.

  1. Gibbons et al. ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina - Summary Article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J. Am. Coll. Cardiol. 2003; 41(1):159-168.
    Available at: http://www.acc.org/qualityandscience/clinical/guidelines/stable/summary_article.pdf
  2. Gibbons et al. ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Full Text Practice Guideline.
    Available at: http://www.acc.org/qualityandscience/clinical/guidelines/stable/stable_clean.pdf
  3. Fraker et al. 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients With Chronic Stable Angina. J. Am. Coll. Cardiol.2007; 50(23):2264-2274
    Available at: http://content.onlinejacc.org/cgi/reprint/50/23/2264

    It is recognized that patient selection for cardiac angiography at a given hospital depends upon the availability of cardiac surgery capability. The following guideline addresses patient eligibility for diagnostic cardiac catheterization at hospitals with cardiac surgery capability, at hospitals without cardiac surgery capability, and at freestanding laboratories.

  4. Bashore et al. American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J. Am. Coll. Cardiol. 2001; 37(8): 2170-2214

    Available at: http://www.acc.org/qualityandscience/clinical/consensus/angiography/cath_PDF.pdf

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

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