New York State Medicaid Update - February 2013 Volume 29 - Number 3

In this issue...

Policy and Billing Guidance

Reimbursement Available to Family Planning Clinics Dispensing Oral Contraceptives to Medicaid Recipients

Effective January 1, 2013, reimbursement is available to family planning clinics dispensing oral contraceptives to Medicaid recipients. This includes both individuals enrolled in the Family Planning Benefit Program (FPBP) as well as other Medicaid recipients who are eligible for family planning services.

Claims must be billed through APGs and should contain the following:

  • CPT code S4993* should be billed for all oral contraceptives.
  • Claims must contain the number of units. One unit is equivalent to a one-month supply of oral contraceptives. Up to three units may be billed.
  • Providers must append the UD modifier to the line if the drug is purchased at the 340B price.

*Note: CPT code S4993 (oral contraceptive) may only be billed in conjunction with a family planning visit. CPT code S4993 is not a stand-alone code so it must be accompanied by another covered service (e.g., evaluation and management service). Providers must include the acquisition cost to be paid for S4993 through APGs. The recipient should be given a prescription for ongoing oral contraceptives which she may then take to a pharmacy. CPT code S4993 cannot be used for refills.

BILLING AND CLAIMING REMINDER

When submitting claims to Medicaid for reimbursement for the vaginal ring or the hormone patch, the CPT codes (outlined in table below) must be submitted on the APG claim, not on a separate ordered ambulatory claim. If the claim is submitted as ordered ambulatory, it will be denied.

J7303 CONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL RING, EACH
J7304 CONTRACEPTIVE HORMONE PATCH

A complete list of all approved procedures under the FPBP is available online at: http://www.emedny.org/ProviderManuals/communications/List_CMS_Approved_FP_Procedures_FPBP_Sept_2010_MA%20Update10-06-10.pdf.

For claiming questions please contact the eMedNY Call Center at (800) 343-9000. For Medicaid policy questions, please contact the Office of Health Insurance Programs (OHIP) at (518) 473-2160. For questions about managed care or Family Health Plus enrollees, please contact the enrollee's health plan.

New York Medicaid Electronic Health Records Incentive Program Update

The New York State Department of Health (NYSDOH) is pleased to announce that as of February 1, 2013, the New York Medicaid Electronic Health Records (EHR) Incentive program has now paid over $284 million in federal incentive funds to over 4,450 New York State hospitals and healthcare practitioners.

The New York Medicaid EHR Incentive program is now accepting attestations from eligible professionals (EPs) and eligible hospitals (EHs) for both adoption/implementation/upgrade (in providers' first year of participation) and meaningful use (for providers' second participation year).

Hospitals who are participating in both the Medicare and Medicaid EHR Incentive Programs will be required to complete their meaningful use attestation for the Medicare EHR Incentive Program using the CMS Registration & Attestation System prior to attesting in the New York Medicaid EHR Incentive Program Application Support Service (MEIPASS).

EPs have until March 31, 2013, to attest in MEIPASS for Payment Year 2012 as their first or second participation year. Payment Year 2012 has officially closed for eligible hospitals as of January 31, 2013. New York Medicaid encourages all providers to attend our revised Participation Year 1 and 2 webinars to view enhancements recently made in the MEIPASS application.

All providers are encouraged to make sure they have maintained all the Program prerequisites and eligibility requirements prior to attesting. This includes enrollment as a fee-for-service Medicaid provider, having an active ePACES login and calculating Medicaid eligibility requirements.

If you have not yet registered for the New York Medicaid EHR Incentive program, we encourage you to visit the new and improved website at https://www.emedny.org/meipass/ or attend one

Wednesday, March 6 12:00-1:00PM Program Prerequisites
Thursday, March 7 12:00-1:00PM EP Participation Year 1 (A/I/U)
Thursday March 14 10:00-11:00AM EP Participation Year 2 (MU)
Tuesday, March 19 12:00-1:00PM EP Participation Year 1 (A/I/U)
Wednesday, March 20 3:00-4:00PM Program Prerequisites
Thursday, March 21 12:00-1:00PM EH Participation Year 2 (MU)
Tuesday, March 26 12:00-1:00PM EP Participation Year 2 (MU)
Thursday, March 28 10:00-11:00AM EP Support Documentation

The webinar schedule is subject to change based on interest levels. To view the complete schedule or to register for one of the webinars, please view the webinar schedules posted on the eMedNY.org website

Uniform Assessment System for New York (UAS-NY) Statewide Implementation Overview

In March 2013, the New York State Department of Health (NYSDOH) begins the implementation of the Uniform Assessment System for New York (UAS-NY). The goal of the UAS-NY is to utilize a comprehensive assessment system within eight Medicaid community-based long-term care services and programs. The UAS-NY:

  • o evaluates an individual's health status, strengths, care needs, and preferences that guides the development of individualized long-term care service plans;
  • assists with program eligibility determinations and identification of program options;
  • improves care coordination and facilitates service delivery; and,
  • ensures that individuals with long-term care needs receive the right care, within the right setting, and at the right time.

The UAS-NY is a web-based software application. It establishes a single, unique record for individuals in the state's Medicaid home and community-based long-term care network. In one location, health care providers will have access to an individual's demographic information, residential and service delivery addresses, assessment information, and assessment outcome information. The availability of information to the appropriate providers will support care planning and service delivery for an individual.

The UAS-NY includes the following three assessment instruments:

  • UAS-NY Community Assessment, a comprehensive assessment used for adults, age 18 and over, in home and community-based long-term care programs;
  • UAS-NY Pediatric Assessment for Ages 4 through 17;
  • UAS-NY Pediatric Assessment from Birth through Age 3.

Reporting capabilities within the UAS-NY allows users to immediately access individual and aggregate reports. The UAS-NY also includes an ad hoc reporting function that will enable users to create customized reports and to download information from the UAS-NY. This data can then be uploaded to an organization's data system.

The UAS-NY will be used in the following Medicaid programs: Adult Day Health Care, Assisted Living Program, Care at Home I and II, Managed Long Term Care (PACE, MAP, MLTC), Long Term Home Health Care, Personal Care, Consumer Directed Personal Care, Nursing Home Transition and Diversion Waiver, and Traumatic Brain Injury Waiver.

UAS-NY STATEWIDE IMPLEMENTATION

NYSDOH will begin the transition to the UAS-NY in March 2013. Organizations will be assigned to one of seven implementation phases. During the transition phase to which organizations are assigned, they will complete specified tasks including staff training, identifying computer resources, setting up HCS accounts, and reviewing and adjusting business practices.

The first phase of the implementation will serve as a pilot of the UAS-NY and will build on the beta test conducted during the summer of 2012. Broome, Chautauqua, Otsego, and Warren counties, which were involved in the beta test, will participate in this phase. Additionally, all home and community-based long-term care service providers within these four counties will also participate in the pilot. Information recorded in the UAS-NY during the pilot will be "real," therefore pilot organizations will continue to use the UAS-NY for all assessments going forward.

Remaining plans and programs will implement the UAS-NY according to the following schedule:

Plans/Counties Begin Transition
Activities
Full Implementation Using
Only the UAS-NY
Managed Long Term Care Plans March 1, 2013 July 1, 2013
Allegany, Cattaraugus, Chemung,
Erie, Genesee, Livingston, Monroe,
Niagara, Ontario, Orleans, Schuyler,
Seneca, Wayne, Wyoming, Yates
May 1, 2013 October 1, 2013
Cayuga, Chenango, Cortland,
Delaware, Herkimer, Jefferson, Lewis,
Madison, Oneida, Onondaga,
Oswego, St. Lawrence, Tioga,
Tompkins
June 1, 2013 November 1, 2013
Albany, Clinton, Columbia, Essex,
Franklin, Fulton, Greene, Hamilton,
Montgomery, Rensselaer, Saratoga,
Schenectady, Schoharie, Washington
July 1, 2013 December 1, 2013
Dutchess, Orange, Putnam,
Rockland, Sullivan, Ulster
August 1, 2013 January 1, 2014
Nassau, New York City, Suffolk,
Westchester
September 1, 2013 February 1, 2014

UAS-NY project staff will contact organizations prior to the respective "Begin Transition Activities" date and will provide materials to support the organization’s transition to and implementation of the UAS-NY.

Additional information concerning the UAS-NY, including the instruments that will be replaced, is available on the Department's website at:

http://www.health.ny.gov/health_care/medicaid/redesign/supplemental_info_mrt_proposals.htm

Questions concerning the UAS-NY may be e-mailed to: uasny@health.state.ny.us

Assisted Living Program (ALP): Rate Code Crosswalk

The Office of Health Insurance Programs (OHIP) Division of Long Term Care will begin a regional implementation of the Uniform Assessment System for New York (UAS-NY) in March 2013. The overall goal of the UAS-NY is to utilize a comprehensive assessment system within eight community-based long-term care programs in order to unify and strengthen the assessment process and outcomes.

The UAS-NY will replace the DSS-4449B and DSS-4449D assessment tools used for Assisted Living Program (ALP) recipients as well as the PRI tool used for determining programmatic eligibility and RUGS-II groups used for billing. Programs will stop using the PRI tool for billing once they begin using the UAS-NY.

The UAS-NY uses the RUGS-III HC classifications rather than the PRI RUGS-II classifications which ALPs are currently required to use for billing. ALPs will be required to crosswalk the RUGS-III HC classifications associated with the recipient's assessment in the UAS-NY to the related RUGS-II for billing purposes as the PRI tool is replaced by the UAS-NY. The RUGS and rate code cross walk is as follows:

RUGS III HC PRI RUGS II
RUGS Category RUGS Group RUGS Category RUGS Group Rate Code Rate Description
Rehabilitation Heavy Rehabilitation
RB0 RB 3303 RUGS II GROUP-RB, NON-MEDICARE
RA2, RA1 RA 3301 RUGS II GROUP-RA, NON-MEDICARE
Extensive Services Special Care
SE3 SB 3307 RUGS II GROUP-SB, NON-MEDICARE
SE2, SE 1 SA 3305 RUGS II GROUP-SA, NON-MEDICARE
Special Care and
Clinically Complex
Clinically Complex
SSB, CCO CD 3315 RUGS II GROUP-CD, NON-MEDICARE
SSA CC 3313 RUGS II GROUP-CC, NON-MEDICARE
CBO CB 3311 RUGS II GROUP-CB, NON-MEDICARE
CA1, CA2 CA 3309 RUGS II GROUP-CA, NON-MEDICARE
Impaired Cognition
and Behavior
Problem
Severe Behavior
IBO, BBO BC 3321 RUGS II GROUP-BC, NON-MEDICARE
IA2, BA2 BB 3319 RUGS II GROUP-BB, NON-MEDICARE
IA1 BA1 BA 3317 RUGS II GROUP-BA, NON-MEDICARE
Physical Function Physical
PDO PE 3331 RUGS II GROUP-PE, NON-MEDICARE
PCO PD 3329 RUGS II GROUP-PD, NON-MEDICARE
PBO PC 3327 RUGS II GROUP-PC, NON-MEDICARE
PA2 PB 3325 RUGS II GROUP-PB, NON-MEDICARE
PA1 PA 3323 RUGS II GROUP-PA, NON-MEDICARE

Additional instructions will be included in the Dear Administrator Letter (DAL). The UAS-NY is not a nursing home admission tool and therefore the PRI will still be required for nursing home admissions. Questions concerning the UAS-NY may be e-mailed touasny@health.state.ny.us

Mandatory Compliance Program Certification Requirement under the NYS Social Services Law Recommendation for Self-Assessment

THIS IS A REMINDER FROM THE NEW YORK STATE OFFICE OF THE MEDICAID INSPECTOR GENERAL (OMIG) FOR ALL MEDICAID PROVIDERS WHO ARE SUBJECT TO THE MANDATORY COMPLIANCE PROGRAM REQUIREMENT.

This updates and revises a portion of the New York State Medicaid Update that was published by the New York State Department of Health (NYSDOH) in June 2012 (Volume 28 - Number 7). This Medicaid Update specifically revises the portion of the Medicaid Update that addresses OMIG's recommendation for self-assessment of Medicaid providers' mandatory compliance programs under New York State's Social Services Law (SSL) §363-d.

This Medicaid Update article is a reminder that OMIG highly recommends that all Medicaid providers conduct a self-assessment of their compliance programs annually. A self-assessment will maximize a provider's opportunity to make improvements, corrections, or refinements to their compliance programs prior to the December certification period for the SSL.

The following identifies the Medicaid providers that are required to have SSL compliance programs. If a Medicaid provider is required to have a compliance program they also are required to certify on OMIG's website, www.omig.ny.gov, that its compliance program meets the requirements of the applicable law and regulations. SSL § 363-d and Title 18 of the New York State Codes, Rules and Regulations (NYCRR) Part 521, both entitled Provider compliance programs, have been actively enforced by OMIG since 2009. This regulation requires all Medicaid providers who fall under the following categories to certify in December of each year that they have adopted, implemented and maintained an effective compliance program.

  • persons subject to the provisions of Articles 28 or 36 of the New York State Public Health Law;
  • persons subject to the provisions of Articles 16 or 31 of the New York State Mental Hygiene Law;
  • other persons, providers or affiliates who provide care, services or supplies under the Medicaid program, or persons who submit claims for care, services or supplies for or on behalf of another person or provider for which the Medicaid program is or should be reasonably expected by a provider to be a substantial portion of their business operations.

Under 18 NYCRR § 521.2 (b), "substantial portion" of business operations means any of the following:

  • 1. when a person, provider or affiliate claims or orders, or has claimed or has ordered, or should be reasonably expected to claim or order at least $500,000 in any consecutive 12-month period from the medical assistance program;
  • 2. when a person, provider or affiliate receives or has received, or should be reasonably expected to receive at least $500,000 in any consecutive 12-month period directly or indirectly from the medical assistance program; or
  • 3. when a person, provider or affiliate who submits or has submitted claims for care, services, or supplies to the medical assistance program on behalf of another person or persons in the aggregate of at least $500,000 in any consecutive 12-month period.

Each compliance program must contain the eight elements required under SSL § 363-d and 18 NYCRR §521.3 (c). Upon applying for enrollment in the medical assistance program, and during the month of December each year thereafter, 18 NYCRR 521.3 (b) requires providers to certify to the Department and OMIG that a compliance program meeting the requirements of the regulation is in place.

Additionally, New York State's Medicaid providers are advised to review OMIG's website and review the compliance related resources available under the Compliance tab. The compliance resources published there may be helpful in preparing for the annual certification; assessing if providers' compliance programs comply with the requirements for all compliance programs; and, addressing some common compliance related questions.

Finally, OMIG has updated the New York Medicaid's form for Provider Certification of Effective Compliance Programs each year since 2009. If OMIG updates the form in the future, it will be announced in a Medicaid Update and also on OMIG's website.

It is the Medicaid provider's responsibility to determine if the provider and its affiliates have adopted, implemented and maintained a compliance program that meets the requirements under SSL § 363-d and 18 NYCRR Part 521. It is expected that the results of a Medicaid provider's assessment of its compliance program will determine whether the Medicaid provider can certify that its compliance program is meeting the statutory and regulatory requirements.

New York Medicaid providers are urged to sign-up for e-mail notices from OMIG by subscribing to OMIG's listserv. The listserv is a great way to keep informed of new compliance policies. Compliance regulations, the certification form, and FAQ's are available on the OMIG website at: http://www.omig.ny.gov

If you have any questions, please contact OMIG's Bureau of Compliance at (518) 408-0401 or by contacting the Bureau of Compliance via e-mail at:compliance@omig.ny.gov.

Compliance Program Guidance for General Hospitals

New York State Office of the Medicaid Inspector General Publication Announcement

This updates and revises a portion of the New York State Medicaid Update that was published by the New York State Department of Health in June 2012 (Volume 28 - Number 7). This Medicaid Update article specifically revises the portion of the Medicaid Update that addresses the New York State Office of the Medicaid Inspector General's publication of the Compliance Program Guidance for General Hospitals.

On May 11, 2012, the New York State Office of the Medicaid Inspector General (OMIG) published the Compliance Program Guidance for General Hospitals. The Guidance is available on OMIG's website,http://www.omig.ny.gov and is located in the compliance library under the compliance tab.

Although the Guidance applies specifically to general hospitals, many other Medicaid providers required to implement and maintain an effective compliance program under New York State Social Services Law (SSL) § 363-d and Title 18 of the New York State Codes, Rules and Regulations (NYCRR) Part 521 may find the Guidance to be helpful as they implement and maintain their compliance programs. The eight elements that are required of all Medicaid providers' compliance programs are the same, but how hospitals operate, provide care and are managed may be different from other Medicaid provider types. The Compliance Program Guidance for General Hospitals is a guide and does not, on its own, carry the force of law or regulation. It was prepared to help general hospitals implement and maintain effective compliance programs required under SSL §363-d and 18 NYCRR Part 521.

New York Medicaid providers are urged to sign-up for e-mail notices from OMIG by subscribing to OMIG’s listserv. The listserv is a great way to keep informed of new compliance policies. Compliance regulations, the certification form, and FAQ's are available on the OMIG website at: http://www.omig.ny.gov. If you have any questions, please contact the OMIG Bureau of Compliance at (518) 408-0401 or via e-mail to: compliance@omig.ny.gov.

PHARMACY UPDATE

Medicaid Pharmacy Prior Authorization Programs Update

Effective March 21, 2013, the fee-for-service pharmacy program will implement the following parameters which include step therapy and frequency/quantity/duration (F/Q/D) requirements. These changes are the result of recommendations made by the Drug Utilization Review Board (DURB) at the December 7, 2012, DURB meeting:

Short-Acting Opioids

  • Duration limit of 90 days for patients without a diagnosis of cancer or sickle-cell disease (excluding tramadol containing products).

Metozolv ODT (metoclopramide)

  • Require trial with conventional metoclopramide before metoclopramide ODT (electronic bypass for previous therapy with conventional metoclopramide or diagnosis of diabetes).
  • Quantity limit of 4 units per day, 120 units per 30 days.
  • Duration limit of 90 days.

Xifaxan (rifaximin)

  • Require diagnosis of hepatic encephalopathy or traveler's diarrhea (electronic bypass for covered diagnosis identified in the claims system).
  • Require trial of a preferred fluoroquinolone before rifaximin for the diagnosis of traveler's diarrhea.
  • Quantity limit of 60 tablets per 30 days of the 550 mg tablets for the diagnosis of hepatic encephalopathy (recommended dose is 550 mg given 2 times daily).
  • Quantity limit of 9 tablets per 30 days of the 200 mg tablets for the diagnosis of traveler's diarrhea (recommended dose is 200 mg given 3 times daily for 3 days).

Acthar H.P. Gel (repository corticotropin injection)

  • Require diagnosis for Medicaid covered uses (electronic bypass for covered diagnosis identified in the claims system. FFS pharmacy benefit does not cover for diagnosis purposes)
  • Require trial of first-line therapy for all FDA-approved indications other than infantile spasms (infantile spasms in children less than 2 years of age – step therapy not required).
  • Duration limits based on diagnosis:
  • Infantile spasms: 4 weeks (indicated for <2 years of age)
  • Multiple sclerosis (MS): 5 weeks
  • Rheumatic disorders: 5 weeks
  • Dermatologic conditions: 5 weeks
  • Allergic states (serum sickness): 5 weeks
  • Quantity limit of 30 mL (six 5 mL vials) for infantile spasms.
  • Quantity limit of 35 mL (seven 5 mL vials) for MS.

Following is a link to the most up-to-date information on the Medicaid FFS Pharmacy Prior Authorization Programs. This document contains a full listing of drugs subject to PDP, CDRP, the Drug Utilization Review Program and the Mandatory Generic Drug Program (MGDP):

https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf

To obtain a prior authorization (PA), please call the prior authorization clinical call center at (877) 309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain PA.

Medicaid enrolled prescribers with an active e-PACES account can initiate PA requests through a web-based application PAXpress®. The website for PAXpress is https://paxpress.nypa.hidinc.com/. The website may also be accessed through the eMedNY website at http://www.eMedNY.org as well as Magellan Medicaid Administration's website at http://newyork.fhsc.com.

Reminder: Medicaid to Cease Support of the OMNI 3750 POS Card Swipe Terminals on March 31, 2013

As published in previous Medicaid Update newsletters, Medicaid will discontinue support of the OMNI 3750 Point of Service (POS) terminal on March 31, 2013. Providers who currently use the Omni 3750 POS terminals to verify Medicaid eligibility or request Dispensing Validation System (DVS) prior approval must make plans to switch to one of the following real-time methods prior to the March 31, 2013 date.

  • Electronic Provider Assisted Claim Entry System (ePACES).
  • eMedNY Simple Object Access Protocol (SOAP). SOAP does not support DVS transactions.
  • Several large clearinghouses and service bureaus support real-time connections to eMedNY (If you require DVS, verify DVS availability with the clearinghouse prior to contracting.)

Providers should visit www.emedny.org to determine which alternate method best meets their needs. Questions and requests for technical assistance on transitioning to an alternate access method may be forwarded via e-mail to emednyproviderservices@csc.com or providers may contact the eMedNY Call Center at (800) 343-9000.

Providers participating in the Card Swipe program who have 3750 terminals will receive a separate letter from the New York State Office of the Medicaid Inspector General (OMIG) on the status of their involvement in the Card Swipe program.

IRS Form 1099

Computer Sciences Corporation (CSC), the 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 1099s are issued with the individual provider’s social security number or for businesses, with the Federal Employer Identification Number (FEIN) registered with New York Medicaid.

As with previous years, please note that the IRS 1099 amount is not based on the date of the checks/EFTs; rather, it is based on the date the checks/EFTs were released to providers.

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

The IRS 1099 that will be issued for the year 2012 will include the following:

  • Check dated 12/19/11 (Cycle 1791) released on 01/04/2012 through,
  • Check dated 12/10/12 (Cycle 1842) released 12/26/12.

Additionally, each year, CSC receives calls from individual providers who are issued 1099s for funds the practitioner is unaware of. In order for group practice providers to direct Medicaid payments to a group NPI and corresponding IRS 1099 for the group, group practices must submit the group NPI in the appropriate field on the claim (paper or electronic). Claims that do not have the group NPI entered will cause payment to go to the individual provider and their IRS 1099. Regardless of who deposits the funds, the 1099 will be issued to the individual provider when the funds have been paid to the individual provider's NPI.

It is imperative that providers keep their addresses current. An incorrect address will impact the provider’s ability to receive their 1099 form in a timely manner.

Please note that 1099s are not issued to providers whose yearly payments are less than $600.00.

IRS 1099s for the year 2012 will be mailed no later than January 31, 2013.

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.

Provider Directory

  • Office of the Medicaid Inspector General: For general inquiries or provider self-disclosures, please call (518) 473-3782. For suspected fraud complaints/allegations, call 1-877-87FRAUD (1-877-873-7283), or visit www.omig.ny.gov.
  • Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules: Please visit the eMedNY website at: www.emedny.org.
  • Providers wishing to hear the current week's check/EFT amounts: Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount)
  • Do you have questions about billing and performing MEVS transactions? Please call the eMedNY Call Center 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 e-mail: emednyproviderrelations@csc.com.
  • Enrollee Eligibility: Call the Touchtone Telephone Verification System at (800) 997-1111.
  • Need to change your address? Does your enrollment file need to be updated because you've experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment? Visit www.emedny.org/info/ProviderEnrollment/index.aspx and choose the link appropriate for you (e.g., Physician, Nursing Home, Dental Group, etc.)
  • Do you have comments and/or suggestions regarding this publication?
  • Please contact Kelli Kudlack at: medicaidupdate@health.state.ny.us.