DOH Medicaid Update January 2000 Vol.15, No.1

Office of Medicaid Management
DOH Medicaid Update
January 2000 Vol.15, No.1

State of New York
George E. Pataki, Governor

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

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management,
14th Floor, Room 1466,
Corning Tower, Albany,
New York 12237

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Since April 1999 Qualified Medicare Beneficiaries (QMBs) have not been properly updated on the Medicaid Management Information System but steps are being taken to correct the problem. Once the QMBs are added to Computer Sciences Corporation's (CSC's) files, all claims that were previously denied for edit 01164 RECIP NOT QMB - SVS NOT REIMBURSABLE FOR COS will be resubmitted for processing. There is no need for providers to resubmit claims; this will be done automatically for you. All claims that are payable will be processed in February 2000.

Questions concerning this article should be directed to CSC at the following number:

Practitioner Services: 1-800-522-5518 or (518) 447-9860

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The following article appeared in the July 1996 Medicaid Update and is being re-issued as a reminder to pharmacies and Medicaid recipients of the policies relating to the Medicaid Co-payment Program. It is strongly recommended that the following Recipient Notices be posted in a location in your store which is highly visible to pharmacy customers.

In response to a number of complaints received by this Department regarding the dissemination of co-pay information to Medicaid recipients, we have developed a notice which contains information pertaining to both provider and recipient responsibilities under the Medicaid Co-payment Program. The Notice, in both English and Spanish, is included in this update. We strongly recommend that you post these notices in a location which is clearly visible to Pharmacy customers. Should Medicaid recipients have questions concerning the co-payment requirements, you should refer them to the notice or the toll-free hotline number indicated at the bottom of the form.

We would consider it an unacceptable practice to post information about the Co-pay Program which would deceive the client.

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The New York State Medicaid Program charges a co-payment for many drug and medical supply items. A co-payment is a small amount of money you pay towards the cost of your care. The amounts you may be asked to pay are:

  • $2.00 for Brand Name Drugs
  • $.50 for Generic Drugs and Non Prescription Drugs
  • $1.00 for Sickroom Supplies

You are required to pay the co-payment if you can afford it. If you cannot afford to pay the co-payment, you should tell the pharmacy; they are still required to give you the drug. If the pharmacy gives you the drug and you do not pay the co-payment because you cannot afford to, you still owe the money to the pharmacy. (The State deducts the money from the pharmacy, even if you don't pay.) They may ask you for the money the next time you come in, bill you, or use other legal means to collect the money.

You should never go without a drug or medical service you need because you cannot afford the co-payment. You should also not refuse to pay the co-payment if you can afford to pay. You decide if you can afford the co-payment.

Note: There are certain drugs used to treat mental illness or tuberculosis which do not have a co-payment. Your pharmacist can tell you which drugs are exempt. Family planning and emergency services are also exempt. There is a $100 per year limit on co-payments for any recipient. (The year starts April 1st, of each year).

Also, some people are exempt from co-payments. They are:

  • Children under 21 years of age
  • Pregnant women
  • Medicaid recipients enrolled in a managed care plan
  • Medicaid recipients enrolled in a Home and Community Based Services Waiver (HCBS) or Comprehensive Medicaid Case Management (CMCM) Program
  • People living in community residences certified by the New York State Offices of Mental Health or Mental Retardation and Developmental Disabilities
  • Certain institutionalized recipients

Questions about this program may be directed to the New York State Medicaid Co-payment Hotline at 1-800-541-2831.


Notificación a los Beneficiarios del Medicaid en el Estado de Nueva York

El Programa del Medicaid en el Estado de Nueva York cobra un copago por varios medicamentos y artículos médicos. Un copago es una cantidad pequeña de dinero, que usted paga hacia el costo del cuidado de su salud. Las cantidades que pueden pedírsele que usted cubra son:

  • $2.00 por Medicamentos de Marca Registrada
  • $.50 for Medicamentos Genéricos y Medicamentos Sin Prescripción
  • $1.00 por Artículos de Enfermería

A usted se le requiere cubrir el copago, siempre y cuando usted pueda cubrirlo. Si usted no puede cubrir el copago, debería notificárselo a la farmacia; la farmacia tendrá que proveerle el medicamento aunque usted no pueda cubrir el copago. Si la farmacia le entrega el medicamento y usted no cubre el copago porque usted no puede pagarlo, usted todavía debe ese dinero a la farmacia. (El Estado deduce ese dinero de la farmacia aunque usted no lo pague.) La farmacia puede pedirle el dinero del copago la próxima vez que usted visite la farmacia, o puede ser que le envíe una cuenta o use otros medios legales para cobrar el dinero.

Usted nunca debería encontrarse en una situación en la que no cuente con medicamentos o el servicio médico necesario, para el bienestar de su salud. Usted tampoco debería rehusarse a pagar el copago si usted puede cubrirlo. Usted es el que decide si está en condiciones de cubrir el copago.

Nota: Existen ciertos medicamentos utilizados para tratar enfermedades mentales o la tuberculosis que no requieren un copago. Su farmacéutico puede informarle sobre qué medicamentos están exentos de copago. Los servicios de planificación familiar y de emergencia también están exentos. Existe un límite de $100 por año en copagos para cualquier beneficiario. (El año comienza el 1ero de abril de cada año).

También, algunas personas están exentas de copagos. Estas son:

  • Niños menores de 21 años de edad
  • Mujeres embarazadas
  • Beneficiarios del Medicaid inscritos en un plan de cuidado administrado
  • Beneficiarios del Medicaid inscritos en Programas Dispensados de Servicios Provistos en el Hogar y Basados en la Comunidad (Home and Community Based Services Waiver-HCBS) o en un Programa Comprensivo de Administración de Casos del Medicaid (Comprehensive Medicaid Case Management (CMCM) Program)
  • Personas que viven en residencias comunitarias certificadas por la Oficina de Salud Mental (Office of Mental Health-OMH) o la Oficina para el Retraso Mental e Incapacidades del Desarrollo (Office of Mental Retardation and Developmental Disabilities-OMRDD) del Estado de Nueva York
  • Ciertos beneficiarios institucionalizados

Preguntas acerca de este programa pueden dirigirse a la Línea Informativa gratuita de Copagos del Medicaid en el Estado de Nueva York Ilamando al 1-800-541-2831.

Attention: Mental Health Providers Serving Managed Care Recipients
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This is to advise that you should be receiving notification shortly of new rate codes for Mental Health clinic treatment programs which participate in Comprehensive Outpatient Program Services (COPS) and/or Community Support Program (CSP) and serve Managed Care recipients. Until now, rate code 4098 allowed for one clinic visit per recipient per day. The new codes (4093 - 4097) will allow mental health providers to bill COPS and/or CSP supplements for brief, group collateral and crisis visits in accordance with Office of Mental Health (OMH) regulations. Where appropriate, as detailed in regulation, multiple visits per day are allowed for the new rate codes 4093 - 4097 as well as rate codes 4601 - 4606 for designated children's interim specialty clinics.

Also, additional editing has been implemented which requires providers to bill within the appropriate rate code series specific to recipients receiving care through:

Service TypeClinic Treatment ProgramDesignated Children's Interim Specialty ClinicsManaged Care COPS and/or CSP only Supplement
Group Collateral430546054094

For example:

  1. If a recipient is not enrolled with a managed care plan and receives all their care through fee-for-service providers, the mental health provider can bill MMIS for the service, COPS and/or CSP supplement, using only rate codes 4301 - 4306 for that recipient.
  2. If a child who meets the definition of serious emotional disturbance receives health care through a managed care provider and mental health care through a designated interim specialty clinic, designated specialty clinics can bill MMIS for the service and the COPS and/or CSP supplement using only rate codes 4601 - 4606 for that recipient.
  3. If a recipient is enrolled in Medicaid managed care and receives mental health clinic services through an OMH licensed COPS and/or CSP clinic, the provider can bill MMIS for the COPS and/or CSP supplement associated with the clinic services using only rate codes 4093 - 4098 for that recipient.

This payment policy is effective for service dates beginning 2/1/99.

If you have any questions about these new rate codes or COPS or CSP in general, please call Bill Hart or Rick Tenenini, OMH Bureau of Community Budget and Fiscal Services, at 518-474-5968.

Schedule of Medicaid Seminars for New Providers

Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:

  • Overview of MMIS
  • Explanation of MMIS Provider Manual
  • Discussion of Medicaid Managed Care
  • Overview of Billing Options
  • Explanation of 90-day Regulation
  • Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend below:

March 28  10 AM
Computer Sciences Corporation
800 North Pearl Street, Third Floor
Albany, NY

March 28  10 AM
Utica, NY (address to be announced - see below)

March 29  10 AM
Carmel, NY (address to be announced - see below)

April 5  10 AM
Buffalo, NY (address to be announced - see below)

May 10  10 AM
Poughkeepsie, NY (address to be announced - see below )

July 19  10 AM
Nassau County Department of Social Services
101 County Seat Drive
Mineola, NY

Other seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.

Please complete the following registration information:

Provider Name:__________________________________________Provider ID:__________________

Provider Category of Service:_______________________________Number Attending:____________

Contact Name:___________________________________________Phone Number:______________

If the seminar address is not listed above, a CSC representative will contact you at least two weeks prior to the seminar date to confirm attendance and provide seminar address information. Each seminar will last approximately two hours. Providers who have questions about these seminars can call CSC at the following numbers:

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

To register, please mail this completed page to:
Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, you may fax a copy of the completed page to:

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.

Thank you for participating in New York State's Medicaid Program.

Please note the following new item codes (noted in bold type) and product description changes, effective for dates of service on or after February 1, 2000, for pressure pads and wheelchair accessories. Underlined code numbers indicate that prior approval is required. A copy of this article should be placed in your DME Provider Manual (Rev. 4/99).

E0192 Low pressure and positioning equalization pad for wheelchair (per pad)
Provides minimum to moderate postural support and moderate to maximum skin protection; 2" and greater thickness; skin protection through pressure reduction on sitting surfaces and/or weight bearing surfaces of trunk (ex: Jay Rave, Roho LP/HP/Quadtro/Enhancer, Varilite, Ulti-Mate PinDot Action, Stimulite).
E0963 P2" cushion, for wheelchair (per cushion)
Provides comfort, postural or lumbar-sacral support and skin protection; supports or reduces moderate deformity(ex: Jay Basic, PinDot SDC, Solid Seat Insert, Jay Combi Lumbar, Varialite Lumbar).
E0964 3" cushion, for wheelchair
Provides comfort, postural support and skin protection; supports or reduces moderate deformity (ex: Jay Basic, PinDot SDC, Solid Seat Insert).
E0965 4" cushion, for wheelchair
Provides comfort, postural support and skin protection; supports or reduces moderate deformity (ex: Jay Basic, PinDot SDC, Solid Seat Insert).
E0980 Safety vest, wheelchair
Includes all straps, harness, vest for safety and positioning.
E1298 Special wheelchair seat depth and/or width, by construction
Provides maximum postural support/minimum skin protection and custom contours (6" or more) using modular design and direct/indirect molding; supports or reduces significant deformity (ex: PinDot Contour U, Custom Foam Modification).
K0031 Safety belt/pelvic strap, each
Use for multiple point belts which provide postural and/or pelvic support, each point up to four points.
K0115 Seating system, back module, posterior-lateral control, with or without lateral support, custom fabricated for attachment to wheelchair base
Provides moderate to maximum postural support utilizing full back support; supports or reduces flexible/fixed, asymmetrical /symmetrical deformity; if molded may use direct or indirect methods (ex: PinDot Personal Back or Silhouette, Jay J2, Varialite Modular Back, Procontour).

1-866-NYQUITS (1-866-697-8487)
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In support of Governor Pataki's and Commissioner Novello's smoking cessation initiative, the Medicaid Program began coverage of prescription smoking cessation products effective October 1, 1999. In the December MEDICAID UPDATE, free community and national supports were listed to assist in helping Medicaid patients become smoke-free. This month, we would like to tell you about a free new smoking cessation service available to you and your patients.

Medicaid recipients who are trying to stop smoking can call the New York State Smokers Quitline to get help. The Smokers Quitline, based at the Roswell Park Cancer Institute and funded through the New York State Department of Health, provides information to callers on a variety of smoking cessation topics and services including tips to stop smoking, smoking cessation aids, and local smoking cessation programs.

The Smokers Quitline also serves as an adjunct to physicians and health care providers in helping their patients break their addiction to nicotine. The Quitline offers smokers a confidential and convenient way to access immediate help when they are ready to stop smoking or need support to remain smoke-free. In addition, health care providers can call the Quitline to obtain office materials that can be shared with patients.

If you would like more information about this program, please call the Quitline at 1-866-NYQUITS (1-866-697-8487). If you would like more information about the Medicaid Program's Smoking Cessation Initiative, please contact the Bureau of Program Guidance at 518-474-9219.

Smoking Cessation Drug Coverage
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The Medicaid Program will begin coverage of over-the-counter (OTC) versions of smoking cessation products effective February 15, 2000.

Reimbursement will be provided for OTC as well as prescription smoking cessation products. OTC products to be covered include nicotine patches (Nicotrol and Nicoderm CQ) and gum (Nicorette). Medicaid coverage is limited to two courses of treatment per recipient per year. A course of treatment is defined as no more than a 90-day supply (an original prescription and two refills).

Effective February 15, 2000, approval through the Dispensing Validation System (DVS) will be required prior to dispensing OTC and prescription smoking cessation agents. Additional information will be provided to pharmacists regarding the use of this system. For further information, contact the Pharmacy Policy Unit at (518) 486-3209.

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The following drugs have been added to the list of drugs which are not included within the cost components of Article 28 Nursing Facility Rates:

Effective DateDrugDosageNDC#
December 7, 1999AvonexInj 33 mcg59627-0001-03
December 7, 1999AvonexInj 30 mcg59627-0001-04
December 7, 1999SeroquelTab 100 mg00310-0271-10
December 7, 1999SeroquelTab 200 mg00310-0272-10
December 7, 1999 SeroquelTab 25 mg00310-0275-10
November 11, 1998SynagisInj 100 mg60574-4111-01

Claims for these drugs that are submitted more than 90 days from the dispensing date must be submitted with a copy of this article. Computer Sciences Corporation (CSC) must receive these claims no later than 12:00 noon on June 1, 2000. Questions regarding submission of pharmacy claims may be addressed to CSC at 1-800-522-5535.

Attention Hospital Providers
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In the current Medicaid Management Information System inpatient claiming configuration, when a Medicaid recipient has commercial insurance, an overpayment of the commercial insurance deductibles and/or coinsurance amount may result if the actual commercial insurance payment amount is recorded. The Department of Health has initiated system changes that will result in the appropriate commercial deductibles and/or coinsurance payments. This change was necessitated by the 1997 Health Care Reform Act legislation, and as such, it potentially impacts Medicaid/other insurance claims with discharge dates on or after January 1, 1997. Providers should not inflate the commercial insurance payment amount on the claim to result in the appropriate payment. Hospitals should void any previously paid claims that resulted in an overpayment and should hold any current claims that would result in overpayment of commercial deductibles and/or coinsurance.

Providers will be notified in a future Medicaid Update when system changes have been implemented that allow for the appropriate payment for commercial deductibles and/or coinsurance from Medicaid. The future Medicaid Update will include instructions for billing commercial deductibles and/or coinsurance including claims which are beyond the two year claiming limitation.

Questions concerning this article should be directed to Robert Pozniak, Bureau of Third Party Liability, at 518-473-1171.

The Medicaid Update: Your Window Into The Medicaid Program

The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: