DOH Medicaid Update Aug 2003 Vol.18, No.8

Office of Medicaid Management
DOH Medicaid Update
August 2003 Vol.18, No.8

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




As mentioned in previous Medicaid Update articles, Computer Sciences Corporation (CSC), on behalf of the New York State Department of Health, has developed the Electronic Provider Assisted Claim Entry System (ePACES). ePACES is a web-based application that allows providers to request and receive HIPAA compliant claims (professional, institutional, and dental), eligibility, claim status inquiry, service authorization, and dispensing validation system transactions.

ePACES is replacing the current Medicaid Eligibility Field Software and the PACES applications. Providers must enroll to use the ePACES application, even if they currently use PACES or the Medicaid Eligibility Software.

Providers will be receiving the ePACES enrollment letter in the mail this summer, with instructions on how to enroll. When the ePACES enrollment process has been completed, the provider's System Administration account will be activated so the provider can start using the web-based ePACES application on September 27, 2003.

After September 27, 2003, the current PACES and Medicaid Eligibility Field Software applications will not be HIPAA compliant.

If you have any questions, please call the HIPAA Help Desk at (866) 840-3445.




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Time is running short. As reported in our past mailings and Medicaid Updates, due to the new HIPAA regulations, the VeriFone TRANZ 330 POS device will need to be replaced or you will be required to switch to an alternate access method to interface with the NYS Medicaid Systems.

Ordering Information
In June, we notified providers about submitting transactions via a POS device. We included instructions and a form for ordering a new device in our notification letter. If you are a POS user and have not received a letter, please call (800) 343-9000 (Option 4) for the Provider Services POS Inquiry Line. This line is available Monday through Friday between 9:00 AM and 5:00 PM. Providers with Internet access can also obtain this information at under "What's New."

About the Omni 3750 (Pricing/Features)
The Omni 3750 has been priced at $817 (includes shipping and handling) plus tax and will include the following features:

  • Five year warranty on hardware failures
  • Expedited Replacement Service (overnight replacement of damaged units)
  • Integrated printer
  • Faster modem for improved transmission speeds
  • Easier to use ATM keys

Please note! As an alternative to using the POS device, the Medicaid Eligibility Field software replacement program called ePACES will be available in September of this year. ePACES will be available to Providers at no cost. We notified providers in July about how to access this system, and an article in the July Medicaid Update also contains more information on ePACES.

You should order now to avoid any delays due to a potential last minute surge of orders prior to the October 16th deadline. Keep in mind that your new Omni 3750 can be used to access eMedNY just like the TRANZ 330, until such time as you receive instructions to download the new HIPAA software. The HIPAA software needs to be installed and working prior to October 16th or an interruption of service could result.

Please contact the Provider Services POS Inquiry Line at (800) 343-9000 (Option 4) if you have any questions.


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All Providers must mail signed Trading Partner Agreements (TPA), filed by their Provider number, to the NYSDOH to be activated to send and receive HIPAA transactions. Providers received hard copies of the TPA in the mail and should return signed copies as soon as possible to Computer Sciences Corporation, Attn. HIPAA TP EDI Coordinator, 800 North Pearl Street, Albany, NY 12204.

In addition, all Trading Partners, defined as the entity that transmits the ANSI X12 HIPAA data directly to NYSDOH, must have signed TPAs filed by Trading Partner ID with NYSDOH. These TPAs will be sent to Trading Partners via email, along with their Trading Partner ID, as Trading Partners register for Edifecs Open Testing at the DOH's website at:

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The following policy was issued in the June 1998 Medicaid Update, and should have been included in the July 2003 Ophthalmic Update document that was mailed to ophthalmic services providers in June 2003.

Optometrists who are appropriately certified by the State Education Department (SED) may bill the NYS Medicaid Program for office-based evaluation and management visits and consultations for the diagnosis and treatment of diseases of the eye.

The billing section of the MMIS Provider Manual for Ophthalmic Services instructs optometrists to leave blank the Diagnosis Code (24F) field (Page 3-43). Diagnosis coding, however, is required on the claim when billing for one of the office-based evaluation and management and/or consultation procedures listed below. Claims without a diagnosis code will deny.

99201  Office visit for evaluation and management of new patient, which requires three key components: a problem focused history, a problem focused examination, and straightforward medical decision-making.

99202   Office visit for evaluation and management of new patient, which requires three key components: an expanded problem focused history, an expanded problem focused exam, and straightforward medical decision-making.

99211  Office visit for evaluation and management of an established patient who presents for follow-up and/or periodic re-evaluation of problems or for the evaluation and management of new problem(s) in established patients.

99212  Office visit for the evaluation and management of an established patient, which requires a problem focused history, a problem focused examination, and/or straightforward medical decision-making.

99242  Office consultation for a new or established patient, which requires three key components: an expanded problem focused history, an expanded problem focused examination, and straightforward medical decision-making.

99243  Office consultation for a new or established patient, which requires three key components: a detailed history, a detailed examination, and medical decision making of low complexity.

99244  Office consultation for a new or established patient, which requires three key components: a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.

Revised Billing Instructions for Completion of Field 24F-Diagnosis Code: Please insert this article in the Billing Section (Page 3-43) of the provider manual. Providers who submit claims electronically or via magnetic media should contact Computer Sciences Corporation at (800) 522-5518 or (518) 447-9860, for help with billing.

24F.     DIAGNOSIS CODE (Block Billing)

Leave this field blank, except when billing for office-based evaluation and management and consultation procedures listed on Pages 4-11 through 4-14 of this manual. Claims for these procedure codes require diagnosis coding.

Using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding system, enter the appropriate code which describes the main condition or symptom of the recipient for which the procedure was performed. The diagnosis code digits should be entered in the correct spaces in relation to the decimal point. Diagnosis codes with subcategories must be entered with the subcategories indicated after the decimal point. A 3-digit diagnosis code (no entry following the decimal point) will only be accepted when the diagnosis code has no subcategories. The following is an example of an ICD-9-CM diagnosis code properly entered in Field 24F:


3        7        2.0


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With implementation of Phase I of eMedNY, the Department enhanced and completed prescribing provider license editing. Specifically, edit 1237 (Prescriber License Not On NYS License File), and edit 1243 (Prescribing Provider Not In Active Status on Date of Service) were activated for claims filed on paper and via magnetic media (tape and diskette). These edits correspond to MEVS response codes 068 (Invalid Ordering Provider) and 318 (Prescribing Provider License Not In Active Status), which continue to be issued for claims submitted via electronically.

Please note that with the enhancements in the editing, the ordering/prescribing ID, either MMIS ID or license number, entered MUST be for the individual practitioner that has order/prescribed the service not the MMIS ID of a group (ie. Physician Group, Dental Group) of which that individual may be a member. If the group ID is entered in the ordering field, the transaction will reject.

Consult your Pharmacy Provider Manual and Medicaid Update articles featuring license editing for information regarding proper use and entry of prescribing provider license numbers.

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Some providers are misinterpreting eligibility inquiry responses, resulting in the denial of their claims. One of the responses causing confusion is "Family Health Plus."

Family Health Plus (FHPlus) is a New York State health insurance program for uninsured adults. FHPlus covers a comprehensive set of services provided through managed care plans. However, no services are covered by the Medicaid program outside of the managed care plan benefit package.

You should be aware of the meanings of the messages/codes that are returned by eMedNY MEVS.

If you have any confusion about any of the messages/codes received in response to your inquiry, please consult the eMedNY MEVS Provider Manual, or the eMedNY Pro-DUR ECCA Provider Manual (both available at or call CSC Provider Services at (800) 343-9000, before providing services.

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Man and Report

This month's patient educational tools features an article on "Controlling Your Diabetes" and "Key Clinical Activities for Quality Asthma Care."

The Medicaid program encourages practitioners to copy and distribute the following information to their patients and to share them with their colleagues.

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Keeping your blood glucose (sugar) close to normal helps prevent or delay diabetic problems such as eye, kidney, heart, nerve and foot disease.

To keep your blood glucose at a normal and healthy level, it is important to lead a healthy lifestyle and stick to daily routines that involve exercise, good nutrition and glucose monitoring. Your glucose levels will be affected by how much and what kinds of food are eaten daily as well as what kind and amount of activity is done each day. Taking your medications, doing activity and eating at the same times every day are important when trying to keep a normal and stable blood glucose level. A stable blood glucose (sugar) level is the key to preventing or delaying diabetic conditions.

Good blood glucose (sugar) levels are usually in the following ranges:

  • 90-130 mg/dl on waking and before meals
  • 180 or less - 2 hours after meals
  • 100 - 140 mg/dl at bedtime

The following are suggestions on how to maintain a stable blood glucose level:

Turkey Eggs Orange Strawberry Peas

Food guidelines:

  • Eat regular meals - eat 3 meals and 2 snacks at the same time every day. Eating every 4-5 hours will keep your blood glucose level stable.
  • Eat less sugar - foods with sugar such as cookies, cakes, pastries, candy and sugared cereals will increase blood glucose levels. Drink water and drinks without added sugar.
  • Eat a variety of foods- if you need help with your diet, talk with your doctor about possibly seeing a dietician.
  • Eat less fat - avoid fried foods. Foods that are steamed, baked or broiled are healthier. When eating dairy products such as cheese, milk or yogurt, choose low fat or no cream options.
  • Eat more high fiber foods such as vegetables, beans and fruit.
  • Eat less salt - Salt will increase blood pressure and that could cause circulatory problems. Avoid foods with sodium or salt listed as a major ingredient. Avoid processed foods such as those that come in cans and jars, cold cuts, pickled foods and snacks like potato chips. Do not add salt when cooking. Substitute with herbs and spices.


Treadmill Jog Swim Athletes Exercise

Physical Activity Guidelines:

  • Physical activity will help keep blood glucose (sugar) and weight under control. It will also help the circulation and prevent heart and blood flow problems. Start with a little activity everyday and then add a few minutes on a weekly basis. Pick an activity that is enjoyable for you and discuss this with your doctor. Walking, gardening, and biking are generally safe; however, there are some activities that should not be done by diabetics with certain problems. For example, a person with cataracts should not bend over at the waist or lift heavy objects such as weights and someone with poor circulatory problems in the legs may be advised not to hike or dance.
  • Do some activity everyday at approximately the same time if possible. It's better to walk 10- 20 minutes daily than to walk an hour once a week.

Medicine Pharmacist Clipboard

Medication guidelines:

  • Take your prescribed medications at the same time everyday.
    Record blood glucose (sugar) results as well as your medication dose in a diabetic log every day. If your blood glucose (sugar) levels are too high (hyperglycemia) or too low (hypoglycemia), try to figure out why. Maybe you did less exercise on a certain day and so your blood sugar was higher than usual. Or, maybe you ate more food than normal or forgot to take your medication, which would make your glucose levels rise. If you ate less or took more medication than you should have, that would cause low blood sugar. By including these details to explain your glucose results, your doctor will be able to tell if you really need a change in medication doses or if your routine is the problem and you need advice with diet or activity.
  • Remember to bring the diabetic logs to your doctor at each visit.
    Remember: food makes glucose levels rise and insulin and exercise make glucose levels fall.

Source: CDC, " Take Charge of your Diabetes", #3rd edition, 2002 pps. 13-18.
American Diabetes Association, Clinical Practice Recommendations 2003
Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance, 7/03


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Recommendations of the National Asthma Education and Prevention Program

A report titled, "Key Clinical Activities for Quality Asthma Care, Recommendations of the National Asthma Education and Prevention Program" was released in the March 28, 2003 Morbidity and Mortality Weekly Report. The report was developed collaboratively by the Centers for Disease Control and Prevention and the National Asthma Education and Prevention Program (NAEPP). The NAEPP convened a Professional Education Subcommittee to improve the implementation of the Expert Panel Report-2: Guidelines for the Diagnosis and Management of Asthma, released in 1997, and the Expert Panel Report - Update 2002. The purpose of the subcommittee was to develop a report that would define the key clinical activities important to delivering quality asthma care that would result in reducing symptoms and preventing exacerbations, and subsequently reducing the overall national burden of illness and death from asthma. The report is intended to be a companion to the NAEPP Expert Panel Reports.

The Professional Education Subcommittee extracted key clinical activities essential for quality asthma care in accordance with the 1997 EPR-2 guidelines and the EPR--Update 2002. The core set of 10 key clinical activities identified are essential for ensuring that health care delivered to patients with asthma emphasize the prevention aspect of care and address the components of care recommended in the Expert Panel Reports. The action steps listed for each key activity suggest specific ways to accomplish the respective activity. Although the subcommittee report is based on information directed to clinicians, it is not intended to substitute for recommended clinical practices for caring for persons with asthma, nor is it intended to replace the clinical decision-making required to meet individual patient needs. The key clinical activities are not intended for acute or hospital management of patients with asthma but rather for the prevention aspects of managing asthma.

The following chart includes the four essential components of asthma care, key clinical activities, and action steps for providing quality asthma care. The entire key clinical activities report is available at:

The EPR-2: Guidelines for the Diagnosis and Management of Asthma, are available at

The NAEPP EPR -- Update 2002, is available at


Components of Care, Key Clinical Activities, and Action Steps for Providing Quality Asthma Care
Assessment and Monitoring
1. Establish asthma diagnosisEstablish a pattern of symptoms and history of recurrent episodes.
Document reversible airflow using spirometry.
Rule out other conditions.
2. Classify severity of asthmaFollow the NAEPP* classification system and recheck at every visit.
3. Schedule routine follow-up careSee patient at least every 1-6 months according to severity.
Perform spirometry at least every 1-2 years for the stable patient, more often for the unstable patient.
Review medication use, care plan, and self-management skills at every visit.
4. Assess for referral to specialty careRefer to specialty care when referral criteria are met.
Control of Factors Contribution to Asthma Severity5. Recommend measures to control asthma triggersDetermine exposures and sensitivities, including environmental and occupational triggers.
Review ways to reduce exposure to allergens and irritants that provoke asthma symptoms.
Discuss smoking avoidance with every patient who smokes or who is exposed to environmental tobacco smoke.
Assess for EIB* if symptoms occur during exercise, and provide medication and advice to enable physical activity.
6. Treat or prevent comorbid conditionsConsider, particularly, rhinitis, sinusitis, GERD*, or COPD*.
Provide annual influenza vaccination for patients with persistent asthma.
Pharmacotherpy7. Prescribe medications according to severity. Reduce inflammation in patients with persistent asthma with anti-inflammatory medications.
Increase medication if necessary; decrease when possible.
Provide appropriate medications delivery and monitoring devices.
Recommend spacers, nebulizers, or both if needed and consider PFM* for patients with moderate to severe asthma or a history of severe exacerbations.
8. Monitor use of Beta2-agonist drugsReevaluate patients using more than one canister per month of short-acting Beta2-agonist drug.
Education for Partnership in Care9. Develop a written asthma management plan Agree on therapy goals.
Outline daily treatment and monitoring measures.
Prepare an action plan to handle worsening symptoms/exacerbations.
10. Provide routine education on patient self-managementTeach/review:
How and why to take long-term control and quick-relief medications.
Correct techniques for inhaler, spacer, PFM*, and nebulizer as indicated.
Peak flow/symptom monitoring with patients when appropriate.
Factors that worsen asthma and actions to take.
*NAEPP: National Asthma Education and Prevention Program, EIB: exercise-induced bronchoconstriction, GERD: gastroesophageal reflux disease, COPD: chronic obstructive pulmonary disease, PFM: peak flow meter.

Source: "Key Clinical Activities for Quality Asthma, Recommendations of the National Asthma Education and Prevention Program", MMWR March 28, 2003 / 52(RR06); 1-8.

The Medicaid Program reimburses for medically necessary care, services, and supplies needed in the diagnosis and treatment of asthma. For information regarding Medicaid payment of these services, please contact the Bureau of Program Guidance at (518) 474-9219.

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Effective August 1, 2003, Medicaid recipients residing in Manhattan will have the option to enroll in a new Special Needs Managed Care Plan, New York Presbyterian System SelectHealth, referred to as OG-NYPS SelectHealth SN. Providers should make note of this new code in their MMIS Provider Manual under the heading "Recipient Other Insurance Codes". Enrollees can call the New York Medicaid CHOICE Helpline at (800) 505-5678 to find out more about Special Needs Plans (SNPs).

This article explains under what circumstances you may continue to provide services to the SNP enrollee and bill MMIS, versus when you must refer the recipient to the SNP to receive services.

Providers must check the eMedNY Medicaid Eligibility Verification System (MEVS) prior to rendering services to determine the recipient's eligibility and the conditions of Medicaid coverage:

  • If the Medicaid recipient is enrolled in a SNP, the message will read "Eligible PCP".
  • To determine if you can bill MMIS, you must read beyond this message for the insurance and coverage codes, which identify the SNP and the services covered by the respective SNP. Please note that the MEVS coverage codes are general service categories, and do not necessarily mean that a SNP covers all services within the category.

You can bill MMIS and receive payment for any Medicaid services not covered by the SNP.

If you believe that the service is covered by the SNP, you must refer the recipient to the SNP for that service. If, at any time, you are unsure whether or not to provide a service, call the SNP prior to providing the service.

The following chart describes the MEVS messages related to the Medicaid services not covered by the NYPS SelectHealth (therefore, the provider may bill MMIS), and information to assist you in contacting the SNP or local district.


MEVS Messages
MEVS MessageSpecial Needs Managed Care Plan Medicaid Services not Covered
by SNP (bill MMIS) include:*
SNP/ County Contact
Pharmacy, Dental, Methadone Maintenance, COBRA case management, HIV resistance tests, AIDS adult day health care, Personal Care Agency Services, Residential Health Care Facilities,
Outpatient clinic chemical dependence treatment (alcohol and substance abuse) except outpatient detoxification
NYPS SelectHealth SN Provider
Relations (866) 469-7774
Renee Stout
(212) 643-3383

* Please contact the health plan above for additional SNP benefit package information.

If you have questions on how to interpret the MEVS message or need further general eligibility clarification, you should call Provider Services at (800) 343-9000.

If you have billing questions, you may contact Computer Sciences Corporation (CSC) at the following numbers:
Practitioner Services (800) 522-5518, Institutional Services (800) 522-1892, Professional Services (800) 522-5535

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Mental Health Providers: Mental Health Services for SSI/SSI-related recipients enrolled in SNPs

Currently, SSI/SSI-related recipients enrolled in Medicaid managed care plans have mental health services carved out from the benefit package. An "S" is indicated on the MEVS for these SSI/SSI-related recipients when a provider conducts an eligibility verification. Historically, providers have been advised to bill MMIS directly for mental health services for these recipients.

This policy will change for SSI/SSI-related enrollees in SNPs. For SSI/SSI-related SNP recipients, inpatient and outpatient mental health services (as described in "Covered Services" of Appendix K in the SNP model contract) are covered by the plan. Providers are advised that for specific plan ("OG" NYPS SelectHealth), these mental health services are the plan's responsibility when a recipient is indicated as SSI ("S") on the MEVS.

An exception is made for some SSI children in the SNPs. Mental health benefits for some SSI children will be carved out of the benefit package consistent with mainstream managed care for SSI recipients. Please check with the plan to determine status of these children.

Mental Health Specialty Services (as described in "Non-Covered Behavioral Health Services" in Appendix K of the SNP model contract) will remain carved out services for all SNP recipients, including SSI and SSI related SNP recipients. The SNP model contract is available at the following website:

This clarification of mental health services applies to all SNPs, including Healthfirst, MetroPlus, Fidelis HealthierLife and VidaCare, which were announced in previous updates.

Chemical Dependency (Alcohol and Substance Abuse) Providers: SSI/SSI-related recipients enrolled in SNPs will have inpatient chemical dependency services covered by the SNP.

Currently, SSI/SSI-related recipients enrolled in Medicaid managed care plans have inpatient and outpatient treatment and rehabilitation chemical dependency (alcohol and substance abuse) health services carved out from the benefit package (except for detoxification services, which are included in the managed care benefit package). An "S" is indicated on the MEVS for these SSI/SSI-related recipients when a provider conducts an eligibility verification. Providers have been historically advised to bill MMIS directly for inpatient and outpatient chemical dependency (alcohol and substance abuse) services for these recipients.

This policy will change for SSI/SSI-related enrollees in SNPs. For SSI/SSI-related SNP recipients, inpatient chemical dependency (alcohol and substance abuse) services are covered by the plan. Providers are advised that for the specific plan ("OG" NYPS SelectHealth) inpatient chemical dependency services are the plan's responsibility when a recipient is indicated as SSI ("S") on the MEVS.

An exception is made for some SSI children in the SNPs. Consistent with mainstream managed care for SSI recipients, inpatient and outpatient treatment and rehabilitation chemical dependency (alcohol and substance abuse) benefits for some SSI children will be carved out of the benefit package (except for detox services which are included in the managed care benefit package). Please check with the plan to determine the status of these children.

Questions regarding this article can be directed to the Department of Health at (518) 486-1383.

Nursing Homes and Pharmacies

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In a nursing home setting, whenever there are discontinued medications, missed doses, patient transfers, or patient discharges, the nursing home will have "unused" medications on hand. These "unused" medications should be returned to the dispensing/vendor pharmacy. The nursing home pharmacy services provider is required by Title 10 New York Codes, Rules and Regulation (NYCRR) 415.18 (f) to reimburse or credit the nursing home or purchaser of such drug products for the unused medication that is restocked and redispensed. Drugs listed on the "Medicaid Nursing Home Carve-Out List" must be credited back to the Medicaid program. Nursing homes and pharmacies providing pharmacy services to nursing homes are encouraged to review their protocols to assure these requirements are met.

For your information, the regulatory requirements are listed below. They may also be accessed on the Department's web site at:

Title 10 NYCRR 415.18 (f): Return of Unused Medications

(1) When services are provided by a cooperating vendor pharmacy, the facility shall establish policies and procedures which permit either the staff registered pharmacist or consultant registered pharmacist to return to the vendor pharmacy, from which it was purchased, any unused medications or drug products, provided such medication is sealed in unopened, individually packaged, units and within the recommended period of shelf life for the purpose of redispensing and which are in accord with the following provisions:

   (i) Drug products which may be returned are limited to:
       (a) oral and parenteral medication in single-dose hermetically sealed containers; and
       (b) parenteral medication in multiple-dose hermetically sealed containers from which no doses have been withdrawn.

   (ii) The drug products returned show no obvious sign of deterioration.

   (iii) Drug products packaged in manufacturer's unit-dose packages may be returned for redispensing provided that they are redispensed in time for use before the expiration date, if any, indicated on the package.

   (iv) Drug products repackaged by the pharmacy into unit-dose or multiple-dose "blister packs" may be returned for redispensing provided that:
       (a) the date on which the drug product was repackaged, its lot number and expiration date are indicated clearly on the package;
        (b) not more than 90 days have elapsed from the date of the repackaging;
       (c) a repackaging log is maintained by the pharmacy in the case of drug products repackaged in advance of immediate needs.
   (v) "Blister packs".
       (a) Partially used "blister packs" may be redispensed only as returned.
       (b) Partially used "blister packs" may not be emptied and repackaged.
       (c) Additional units of medication may not be added to partially used "blister packs".

   (vi) No drug product dispensed in bulk in a dispensing container may be returned.
   (vii) No medication or drug product defined as a controlled substance in Section 3306 of the Public Health Law may be returned.

(2) The vendor pharmacy to which such drug products are returned shall reimburse or credit the nursing home or purchaser of such drug products for the unused medication that is restocked and redispensed and shall not otherwise charge any individual resident or the State, if a resident is a recipient or beneficiary of a State-funded program, for unused medication or drug products returned for reimbursement or credit.

Please contact the Pharmacy Policy and Operations Unit at (518) 486-3209 or or you can e-mail us at


The following is a correction of the May 2003 Medicaid Update, Patient Educational Tool article entitled, "Hyperglycemia and Hypoglycemia, Potentially Life Threatening Conditions," in which an error was made.

Under the section Causes of Hyperglycemia:

  • "Exercising More Than Planned" was incorrectly listed as a cause.
  • "Exercising Less Than Planned" is a cause for hyperglycemia.

We are reprinting the corrected article in its entirety so that you may copy and redistribute the correct information to your patients. We apologize for this error and thank our readers for notifying us.

Please continue to contact the Medicaid Bureau of Program Guidance at (518) 474-9219 with your comments and suggestions on these and future patient educational tools.

"Potentially Life Threatening Conditions"

Hyperglycemia or high blood sugar occurs when the blood glucose level is higher than 140 mg/dL before meals. Hyperglycemia can become serious if it is not treated and can lead to Ketoacidosis. Understanding the causes of hyperglycemia will prevent complications and ketoacidosis from occurring.

Causes of Hyperglycemia

Eating more food than planned
Exercising less than planned
Illness, even a mild cold or the flu
Stress, family, school, work, etc
Not taking enough insulin

Signs & Symptoms of Hyperglycemia

Dry Mouth
Extreme Thirst
Sugar in the Urine
High Blood Sugar
Mental Confusion
Blurred Vision
Frequent Urination
Stomach/Abdominal Pain
Weight Loss/Vomiting

What You Should Do If You Have Symptoms of Hyperglycemia

**Always Follow the Directions Provided To You By Your Doctor or Medical Provider**

The following recommendations were adapted from the CDC:

Drink 3-5 ounces of non sugared fluid hourly
Continue to take your medications
Test your blood & urine for glucose
Test your urine for ketones
Continue to follow your diet
Walk or do some form of mild exercise
Notify your doctor with your blood and urine results if the situation continues

What is Ketoacidosis?

Ketoacidosis or diabetic coma develops when the body does not have enough insulin to use glucose (sugar) for fuel (energy). Without insulin, the body will break down fats to use for energy. When the body breaks down fats, waste products called ketones are produced. The body cannot tolerate large amounts of ketones and will try to get rid of them in the urine. The body cannot release all the ketones in the urine; as a result they build up in the blood and that can lead to Ketoacidosis.


The Most Common Reason for Ketoacidosis is Forgetting to Take Insulin!

Symptoms of Ketoacidosis Are Life Threatening and Require Immediate Treatment

Shortness of Breath     Fruity Breath     Nausea & Vomiting

Test Your Urine for Ketones Immediately - Call Your Doctor!




Always Wear a Medical Identification Device and Carry a Card That States You Have Diabetes
Carry a List of Your Medications and Dosages and What To Do in Case of an Emergency

Source: CDC, "Take Charge of Your Diabetes", 2nd edition, 1997 pps. 24-30. The American Diabetes Association website, http:
Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance, 5/03

"Potentially Life Threatening Condition"

Hypoglycemia or low blood sugar occurs when the blood glucose level is higher than 70 mg/dL. Hypoglycemia can become serious if it is not treated and you may have seizures or lose consciousness. It is important to understand the causes of Hypoglycemia in order to prevent complications.

Causes of Hypoglycemia

  • Eating less food than usual, and still taking the normal amount of insulin or diabetic medication.
  • More activity or exercise than usual, without eating extra food prior to the exercise.
  • Giving yourself too much insulin or taking more diabetic medication than is normal on a typical day.
  • Drinking alcoholic beverages or other substances that cause your blood sugar to drop.

Signs & Symptoms of Hypoglycemia

     Shakiness     Dizziness      Sweating      Fatigue     Hunger      Headache     Pale skin color     
     Sudden moodiness     Behavioral changes      Difficulty paying attention     Confusion     
     Clumsy or jerky movements     Tingling sensations around the mouth      Loss of consciousness

What You Should Do If You Have Symptoms of Hypoglycemia

**Always Follow the Directions Provided To You by Your Doctor or Medical Provider**

The following recommendations were adapted from the CDC:

  1. Test your blood sugar right away, if less than 60 to 70 mg/dL you need to eat 10 - 15 grams of carbohydrates immediately!

    Examples of 10 - 15 grams of carbohydrates:
    2-3 teaspoons (packets sugar)
    ½ cup or 4 ounces fruit juice
    3-5 pieces of hard candy
    ½ cup or 4 ounces of soda *NOT DIET SODA*
    2-3 glucose tablets

  2. If you feel like your blood sugar is getting low, but you cannot test right away, eat 10 - 15 grams of carbohydrates IMMEDIATELY!
  3. Check your blood sugar again in 15 minutes.
  4. Eat another 10 - 15 grams of carbohydrates every 15 minutes until your blood glucose is above 70 mg/dL or your symptoms have gone away.
  5. Eating one of the above items will keep your glucose up for only 30 minutes. If your next meal is more than 30 minutes away, you should also eat something else.
      (For example: crackers with a tablespoon of peanut butter or cheese)


Be Prepared for an Emergency

  1. Always carry a carbohydrate with you so you will be ready to treat a low glucose level.
    (For example: hard candy or glucose tablets)
  2. Tell your family, friends and co-workers that you have diabetes.
    Tell them how to know when your blood glucose is low. Show them what to do if you cannot treat yourself. Inform them that someone will need to give you fruit juice, OR soda, OR sugar.
  3. If you cannot swallow, someone will need to give you a shot of Glucagon and Call for Help!
    is an injectible prescription medication that raises the blood glucose level.
    **Ask your doctor or medical provider if you should have a Glucagon Emergency Kit available.**
    Teach family members, roommates, friends and co-workers when and how to use Glucagon.




Always Wear a Medical Identification Devise and Carry a Card That States You Have Diabetes
Carry a List of Your Medications and Dosages and What To Do in Case of An Emergency

Source: CDC, "Take Charge of Your Diabetes", 2nd edition, 1997 pps. 24-30. The American Diabetes Association website, http:
Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance, 5/03


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Please let us know if you would like to continue to receive a hard copy of the Medicaid Update in addition to the e-mail version. We don't want to burden you with a paper copy if you do not need it.


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Please mark the address page of the duplicate Medicaid Updates as duplicate, and mail this page to:

Medicaid Update
NYS Department of Health
Office of Medicaid Management
99 Washington Ave., Suite 606
Albany, NY 12210


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A federal requirement of the Family Planning Benefit Program (FPBP) is to ensure that recipients in this program have access to primary health care services when needed. Medicaid reimbursement is not available for primary care coverage, but family planning providers can refer recipients to federally qualified health centers (FQHC), FQHC look-alikes, and community health centers.

The following pages contain a current list of FQHCs, FQHC look-alikes and community health centers that are available for referral for recipients in the FPBP for primary care services.

AlbanyWhitney Young Health CenterLark & Arbor Dr.
Albany, NY
(518) 465-4771
BronxBronx Lebanon Integrated Services Systems (BLISS)
- Grand Concourse
- Crotona Park Family Practice
- Dr. Martin Luther King Health Center
- Family Practice Center
- Bronx Care at Poe
-Tiffany Primary Care Practice

1650 Grand Concourse
1591 Fulton Ave.
1265 Franklin Ave.
1276 Fulton Ave.
1690 Bryant Ave.
2432 Grand Concourse
853 Tiffany St.

(718) 518-5060
(718) 901-6471
(718) 503-7700
(718) 901-8236
(718) 901-6480
(718) 817-7900
(718) 378-4764
 Bronx Community Health Network, Inc.
-Montefiore Comprehensive Family Care Center
- Montefiore Comprehensive Health Care Center
-Montefiore Family Health Center

-Promesa, Inc.

1621 Eastchester Rd.

305 East 161st St.

360 East 193rd St.

1776 Clay Ave.

(718) 405-8040 ext.2338,2339

(718) 579-2500

(718) 933-2400
(718) 960-7500
 Hunts Point Multi-Service Center1675 Westchester Ave.(718) 842-0900
 Hunts Point Multi-Service Center754 E. 151st St.(718) 402-2800
 Institute for Urban Family Health
- Mt. Hope Family Practice
- Parkchester Family Practice
- Urban Horizons Family Health Center
- Walton Family Health Center

130 West Tremont Av.
1597 Unionport Rd.
50 East 168th St.
1894 Walton Ave.

(718) 583-9000
(718) 822-1818
(718) 293-3900
(718) 583-3060
 Morris Heights Health Center85 W. Burnside Ave.(718) 716-4400
 Urban Health Plan1065 Southern Blvd.(718) 589-2440
 Comprehensive Community Development Center731 White Plains Rd.(718) 589-8324
 Soundview Health Center
- Diallo Medical Center
- Castle Hill Medical Center
- Burnside Medical Center
- Delaney Sisters Health Center
731 White Plains Rd.
1760 Westchester Ave.
616 Castle Hill Ave.
165 E. Burnside Ave.
2727 White Plains Rd.
(718) 589-8324
(718) 892-8474
(718) 239-9013
(718) 563-0003
(718) 652-3387
CattaraugusLionel R. John Health Center987 R.C. Hoag Dr. Salamanca, NY(716) 945-5894
CayugaFamily Health Network Central NY6 South Main St. Moravia, NY(315) 497-9066
ChautauquaCattaraugus Indian Reservation Health1510 Rt. 438 Irving,NY (716) 532-5582
CortlandFamily Health Network Central NY 11 Alvena, St. Cortland, NY (607) 758-3008
 Family Health Network Central NYNorth Main St. Cincinnatus, NY(607) 863-4126
 Family Health Network Central NY22-24 East Main St. Marathon, NY(607) 849-3271
Dutchess Hudson River Community Healthcare at Beacon249 Main St. Beacon, NY(845) 831-0400
 Hudson River Community Health3360 Rte. 343 Amenia, NY(845) 373-9006
 Poughkeepsie Community Health Center29 N. Hamilton St. Poughkeepsie, NY(845) 454-8204
ErieCommunity Health Center of Buffalo Inc.462 Grider St. Buffalo, NY(716) 898-4449
 Northwest Buffalo Community Health155 Lawn Ave. Buffalo, NY(716) 875-2904
EssexHudson Headwaters Health Network24 Fairfield Ave. Schroon Lake, NY (518) 532-7120
 Hudson Headwaters Health Network
Ticonderoga Health Center
102 Racetrack Rd. Ticonderoga, NY(518) 585-6708
 Moses Ludington Hospital Ronald B. Stafford Community CareWicker St. Ticonderoga, NY (518) 585-6708
FranklinSt. Regis Mohawk Health SystemsRte. 37 Hogansburg, NY(518) 358-3141
HamiltonHudson Headwaters Health NetworkMain St. Indian Lake, NY(518) 648-5707
Kings (Brooklyn)Bedford Stuyvesant Family Health Center1413 Fulton St. Brooklyn, NY (718) 636-4500
 Brooklyn Plaza Medical Center650 Fulton St.(718) 596-9800
 Brownsville Multi-Service Family Health Center444 Thomas Boyland(718) 345-5503
 Community Healthcare Network- CABS Center94-98 Manhattan Ave.(718) 388-0390
 Community Healthcare Network- Dr. Betty Shabazz Center999 Blake Ave.(718) 277-8303
 East New York Neighborhood Family Clinic2094 Pitkin Ave.(718) 495-2320
 Family Physician Health Center5616 Sixth Ave.(718) 439-5440
 Lyndon B. Johnson Health Complex276 Nostrand Ave.(718) 636-2220
 ODA Health Ctr.14-16 Heyward St.(718) 852-0803
 Park Slope Health Center220-13th St.(718) 832-5980
 Sunset Park Family Health Center of Lutheran Medical Center150 55th St.(718) 630-7095
MadisonFamily Health Network of Central New York57-29 Route 13 De Ruyter, NY (315) 852-3318
 Oneida Nation Health Clinic2 Territory Rd. Oneida, NY(315) 829-8700
MonroeAnthony L. Jordan Health Center82 Holland St. Rochester, NY (585) 423-2879
 Oak Orchard Community Health Center300 West Ave. Brockport, NY(585) 637-3905
 Westside Health Services175 Lyell Ave. Rochester, NY(585) 254-6480
 Westside Health Services480 Genesee St. Rochester, NY(585) 436-3040
 Rochester Primary Care Network, Inc.
- Clinton Family Health Center
- Community Health Network
- Downtown Health Care Center
- Genesee Health Service

- Orchard Street Community Health Center

309 Upper Falls Blvd.
87 N. Clinton Ave.
228 East Main St.
220 Alexander St.
Suite 701-704
158 Orchard St.

(585) 546-2360
(585) 244-9000
(585) 423-1880
(585) 922-8003 or
(585) 436-9224
New York Betances Health Center280 Henry St. New York, NY(212)227-8401
 Boriken Neighborhood Health Center2253 Third Ave.(212) 289-6650
 Charles B. Wang Community Health Center125 Walker St. 2nd floor(212) 226-3888
 Community Healthcare Network- Helen B. Atkinson Center81 West 115th St.(212) 426-0088
 East Harlem Council for Human Services2253 Third Ave.(212) 289-6650
 Renaissance Health Care215 West 125th St.(212) 932-6530
 Ryan-NENA Comprehensive Health279 E. 3rd St.(212) 477-8500
 Ryan Chelsea Clinton Community Health Center645 Tenth Ave.(212) 265-4500
 Settlement Health and Medical Service212 E. 106th St.(212) 360-2600
 William Ryan Community Health Center110 W. 97th St. New York, NY(212) 316-7953
 Institute for Urban Family Health
-Sidney Hillman Family Practice
-East 13th Street Family Practice
-Heritage Health Care

16 East 16th St.
113 East 13th St.
1727 Amsterdam Ave.

(212) 924-7744
(212) 253-1830
(212) 862-0054
OnondagaSyracuse Community Health Center819 S. Salina St. Syracuse, NY (315) 476-7921
 Syracuse Community Health Center1938 East Fayette St. Syracuse, NY (315) 474-4077
 Syracuse Community Health Center603 Oswego St. Syracuse, NY(315) 424-0800
OrangeEzra Choilim Health Center550 Forest Rd. Monroe, NY(845) 782-3242
 Family Health Center of Newburgh3 Washington Ctr. Newburgh, NY (845) 565-3138
 Hudson Valley Migrant Health SatellitePulaski Highway Goshen, NY(845) 651-2298
 Middletown Community Health Center10 Benton Ave. Middletown, NY(845) 343-8838
 Middletown Community Health Center505 Rte. 208 Suite 11 Monroe, NY(845) 783-6091
 Middletown Community Health Center99 Cameron St. Pinebush, NY(845) 744-2067
 Walkill Valley Health Center75 Orange Ave. Walden, NY(845) 778-2700
OrleansOak Orchard Community Health Center301 West Ave. Albion, NY (585) 589-5613
OswegoPulaski Health Center61 Delano St. Pulaski, NY(315) 298-6564
QueensJoseph P. Addabo Family Health Center67-10 Rockaway Beach Far Rockaway, NY (718) 945-7150
 Charles B. Wang Community Health Center136-26 37th Ave. Flushing, NY(718) 886-1200
 Community Healthcare Network - Queens Center97-04 Sutphin Blvd. Jamaica, NY (718) 657-7088
RocklandMonsey Family Health Center40 Robert Pitt Dr. Monsey, NY(845) 352-6800
 Refuah Health Center728 North Main St. Spring Valley, NY(845) 354-9300
SchenectadySchenectady Family Health Services602-608 Craig St. Schenectady, NY(518) 370-1441
TompkinsFamily Health Network of Central NY (Dental)100 Sykes St. Groton, NY (607) 898-5873
UlsterUlster Migrant Health CareOne Paradise Ln. New Paltz, NY(845) 255-1760
WarrenHealth Center on Broad St.100 Broad St. Glens Falls, NY(518) 792-2223
 Hudson Headwaters Health Network11 Cross St. Bolton Landing, NY(518) 644-9471
 Hudson Headwaters Health Network6381 State Rt. 9 Chestertown, NY(518) 494-2761
 Hudson Headwaters Health NetworkSki Bowl Rd. North Creek, NY(518) 251-2541
 Hudson Headwaters Health Network3767 Main St. Warrensburg, NY(518) 623-2844
 Queensbury Family Health Center14 Manor Dr. Queensbury, NY(518) 798-6400
 Moreau Family Health10154 Saratoga Rd. South Glens Falls, NY(518) 761-6961
WayneRushville Health Center6600 Middle Road Suite 2200, Sodus, NY(315) 483-1200
WestchesterGreenburgh Neighborhood Health Center 330 Tarrytown Rd. White Plains, NY(914) 989-7625
 Mt. Vernon Neighborhood Health Center107 West Fourth St. Mount Vernon, NY(914) 699-7200
 Open Door Family Medical Centers Inc.80 Beekman Ave. N. Tarrytown, NY (914) 631-4141
 Open Door Family Medical Centers Inc.165 Main St. Ossining, NY(914) 941-1263
 Open Door Family Medical Centers Inc.90 South Ridge St. Rye Brook, NY(914) 937-8899
 Hudson River Community Health Center (Peekskill Area Health Center)1037 Main St. Peekskill, NY (914) 739-8105
 Yonkers Community Health Center30 South Broadway Yonkers, NY(914) 968-4898
YatesRushville Health Center2 Ruben Dr. Rushville, NY(585) 554-6824

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Due to recent legislative change, Medicaid payment for Medicare coinsurance for most Part B services provided to recipients eligible under both the Medicare and Medicaid Programs - dual-eligibles and Qualified Medicare Beneficiaries - will be reduced. Providers were sent a letter, dated June 6, 2003, signed by Kathryn Kuhmerker, Deputy Commissioner of the Office of Medicaid Management, that described the legislative mandate to change the Medicaid program's payment policy for dual-eligibles. The letter explained that effective July 1, 2003, the Medicaid program will no longer pay the full Medicare Part B coinsurance amount for dual-eligibles, but will instead pay 20% of the Medicare Part B coinsurance for most Part B services (except for ambulance, psychologist, and hospital-based/freestanding clinics). A copy of the June 6, 2003 letter follows these questions and answers.

The following questions and answers clarify policy on this program change.

  • 1.   Q. How is Medicaid's payment of Part B Medicare coinsurance different for dates of service on or after July 1, 2003?
    • A.  For most Part B services, Medicaid's coinsurance payment is being reduced to 20% of the Medicare Part B coinsurance. This is best shown in examples in the chart that follows:

      Part B Medicare Coinsurance Before and After 7/1/2003
       When Medicare pays 80%When Medicare pays 50% (Mental Health Practitioner Services ONLY)
      Before 7/1/2003On or after 7/1/2003Before 7/1/2003 On or after 7/1/2003
      Medicare Approved Amount$100$100$100$100
      Medicare Paid Amount80805050
      Coinsurance Billed to Medicaid20205050
      Medicaid Coinsurance Payment2045010
  • 2.   Q. What services are affected?
    • A.   All Medicare Part B services are affected except those provided by ambulances, psychologists, and hospital-based and freestanding clinics certified by DOH, OMH, OMRDD, or OASAS. These services were specifically exempted by the legislature.
  • 3.   Q. What caused this change in payment? Is it in effect for a certain timeframe?
    • A.  This is a legislative initiative enacted as part of the 2003 NYS budget. There is no end date.
  • 4.   Q. Can the recipient who has both Medicare and Medicaid be billed for any unpaid coinsurance amount?
    • A.   No. The Medicaid/Medicare client must be financially held harmless by participating providers. If a Medicaid provider delivers care or services to a person covered by Medicare and Medicaid, Medicare and Medicaid must be billed. The patient may not be billed.
      Note: Medicaid patients cannot be billed for any covered services, except for Medicaid co-payments (if applicable).
      It is our understanding that Medicare rules prohibit a provider from billing most Medicare/Medicaid eligibles, regardless of that provider's participation in Medicaid. Providers should contact the Medicare program directly for further clarification on this prohibition.
  • 5.   Q. Is the July 1 effective date for 'billing dates' or 'dates of service'?
    • A.  For claims with dates of service on or after July 1, 2003, Medicare Coinsurance will be paid under the new law at the reduced amount.
  • 6.   Q. Am I still allowed to collect any applicable Medicaid co-payments?
    • A.  Yes. Medicaid recipient co-payments remain in effect.
  • 7.   Q. Will providers continue to bill in the same way? How will Medicaid determine what part of the charge went toward the Part B deductible?
    • A.  Providers should continue to bill for the full deductible and coinsurance. Any necessary reductions or corrections will occur in Medicaid's automated claims payment system. Since modifications to the claim payment system will take some time, providers will be notified of any changes in billing procedures in a future issue of the Medicaid Update.
  • 8.   Q. What if Medicaid pays more than Medicare for a given service (e.g., some physician office visits, testing strips)?
    • A.  If the Medicaid fee exceeds the 'Medicare Paid' amount, Medicaid will pay up to the Medicaid fee, but no higher than the 'Medicare Approved' amount. Medicaid's payment will not exceed the Medicare coinsurance amount.
      Medicare Approved Amount and Medicaid Paid Amount
       Example 1Example 2
      Medicare Approved
      Medicare Paid
      Medicare Coinsurance
      Medicaid Fee
      Medicaid Payment
  • 9.   Q. What if the services I provide are not covered by Medicare?
    • A.  You are not affected. Continue to bill as usual.
  • 10.   Q. What if the Medicare/Medicaid split for some of my services is 50/50 (mental health services provided by psychiatrists and clinical social workers)?
    • A.  For psychiatrists and clinical social workers, Medicaid will pay 20% of the coinsurance. (See example in Question # 1 above.) Clinical psychologists will continue to receive Medicaid payment for the full coinsurance.
  • 11.   Q. Is this new payment policy effective in New York State only?
    • A.  Yes. This legislation affects coinsurance payments for all New York State Medicaid beneficiaries (even if they receive treatment in another State). Coinsurance payment policies for Medicaid beneficiaries from other states are not affected by this legislation.
  • 12.   Q. In the June 6 letter, paragraph 3 states that NY Medicaid will continue to pay the full deductible. This appears to be contradicted in paragraph 5 of that letter where it indicates "....may not seek to recover any coinsurance and deductible amounts from Medicaid recipients."
    • A.New York Medicaid will continue to pay the full deductible. Paragraph 5 of the June 6 letter merely restates the principle that Medicaid patients may not be charged for any of the coinsurance and deductible amounts.
  • 13.   Q. I am a physician. We have added a suite to perform colonoscopies (echocardiograms, stress testing). This is an 'outpatient' service. Will this new law be applied to these services also?
    • A.  Yes. Services billed with category of service 0460 (physician) will be subject to the new coinsurance payment methodology.
  • 14.   Q. I am very unhappy with this new law. How can I disenroll from the NYS Medicaid Program?
    • A.  If you wish to disenroll from the Medicaid program, send your signed, written request to:
      NYS Department of Health
      Bureau of Medical Review and Payment
      Attention: Fee-For-Service Provider Enrollment
      Riverview Center 6E
      150 Broadway
      Albany, NY 12204

      As noted in Question #4, it is our understanding that withdrawal from the Medicaid program does not allow you to collect coinsurance and deductible amounts from most Medicare/Medicaid eligible recipients.
      Remaining in the Medicaid program and billing for the coinsurance and deductible maximizes your reimbursement.

  • 15.   Q. If I disenroll from the Medicaid program by sending in a letter, what is the effective date of the disenrollment?
    • A.  The effective date of the disenrollment would be the date requested in your letter. If you do not specify an effective date, the date on the letter will be used. If there is no date on the letter, the date the letter is received/date stamped by the department is used.
  • 16.   Q. If I disenroll from the Medicaid program and wish to re-enroll in the future, does the original disenrollment adversely affect the new enrollment in any way?
    • A.  No, not in the case of a voluntary withdrawal. However, should you request reinstatement at a future date, the effective date of the new application would not be backdated to the date of your original application.
  • 17.   Q. Will disenrolling from Medicaid impact a provider's eligibility/participation in Medicaid Managed Care Plans (e.g., HIP, CDPHP HealthNow, Fidelis Care, etc.)?
    • A.  No. If a provider wishes to disenroll ONLY from fee-for-service Medicaid, they must specify that their enrollment be changed to "non-billing, managed care only" status.
  • 18.   Q. As a Medicaid provider impacted by the new coinsurance legislation, can I stop accepting new Medicaid/Medicaid patients and continue to bill for my current patients who have Medicare/Medicaid?
    • A.  Yes. Providers are not obligated to accept new patients.
  • 19.   Q. Does this payment policy apply to Part B services provided by a hospital that are billed to and paid by the Part A Medicare carrier?
    • A.  No. Clinic providers (categories of service 0160 and 0287) will continue to receive full coinsurance payment.
  • 20.   Q. I am a physician with a speciality in oncology. Does the reduction in Medicaid's payment mean that I will be paid less than my cost for the chemotherapeutic agents?
    • A.  As noted in Question #8, if the Medicaid fee (in this case, your acquisition cost based on invoice) exceeds the "Medicare Paid" amount, Medicaid will pay your acquisition cost
  • 21.   Q. Can I give a prescription for the chemotherapy drugs to the patient and have them obtain the drugs at a pharmacy?
    • A.  The Medicaid formulary file is not intended to substitute for drugs normally furnished through a physician's office; therefore, these drugs may not be available from pharmacies.
  • 22.   Q. Does this new payment policy apply to services provided by a physician or practitioner to a recipient in an inpatient setting? What if services are provided in a DOH-certified clinic (Article 28)?
    • A.  Yes. For all claims submitted for physician services under category of service 0460, Medicaid will pay 20% of the coinsurance amount-regardless of place of service.
  • 23.   Q. Does this change Medicaid's payment of coinsurance impact services provided by private duty nurses? nursing homes/skilled-nursing facilities?
    • A.  No. For services that are not normally covered under Medicare Part B, there will be no change in your current Medicaid reimbursement.
  • 24.   Q. Since the system was not ready for implementation of the new law on July 1, how will claim adjustments be made? What information will providers receive as this is accomplished? How will overpayments be recouped by the State?
    • A.  When systems changes are accomplished, claims will be reprocessed creating payment adjustments. Claim-specific data, including recipient, date of service, procedure and payment amounts will be shown on the remittance statement the provider receives. As each claim (dated July 1, 2003 or after) is reprocessed through the system, negative balances will be created.
  • 25.   Q. Should I "hold" my billing until the system changes are completed to avoid State recoupments of coinsurance overpayments?
    • A.  No. We do not recommend this because claims submitted after 90 days are considered late submissions. Once a claim has been processed by Medicare, it must be submitted to Medicaid within 30 days of the date the Medicare statement was received by the provider.
  • 26.   Q. Are ambulatory surgery and outpatient department services billed by an Article 28 facility subject to the new law?
    • A.  No. Payment for services provided by an Article 29 facility are not affected by the new law.
      If you have additional questions concerning this legislation, please contact the Bureau of Policy Development and Agency Relations at (518) 473-2160.


A copy of the
June 6, 2003 Kathryn Kuhmerker letter
to providers follows below.





     Corning Tower          The Governor Nelson A. Rockefeller Empire State Plaza          Albany, New York 12237

Antonia C. Novello, M.D., M.P.H., Dr. P.H.

Dennis P. Whalen
Executive Deputy Commissioner

June 6, 2003


Dear Medicaid Provider:

This is to inform you that the Legislature enacted new legislation, effective July 1, 2003, that reduces the Medicaid payment for Medicare coinsurance for most Part B services provided to dual eligibles and Qualified Medicare Beneficiaries to 20% of the full coinsurance amount, in instances where the Medicare paid amount is higher than the Medicaid fee [Social Services Law, §367-a(1)(d)].

However, this new law requires Medicaid to continue to pay the full Medicare coinsurance amount for the services provided to Medicare Part B dual eligibles and Qualified Medicare Beneficiaries by ambulance providers, psychologists, clinics certified by the Office of Mental Retardation and Developmental Disabilities (Article 16), the Office of Mental Health (Article 31), the Office of Alcoholism and Substance Abuse Services (Article 32), and outpatient and freestanding clinics certified by the Department of Health (Article 28).

The Medicaid program will also continue to pay the full Medicare deductible amount for dual eligibles and Qualified Medicare Beneficiaries.

Please be advised that if the Department is unable to complete the required changes to the Medicaid billing system by the July 1, 2003 effective date, the Department intends to make retroactive adjustments to recoup any payments made in excess of the reduced coinsurance amounts for claims with dates of service back to July 1, 2003.

Providers of care, services, supplies or equipment covered under Medicare Part B and the Medicaid program must accept assignment of the Part B payment, and may not seek to recover any Part B coinsurance and deductible amounts from Medicaid recipients.

If you have any questions concerning this change in the Medicare coinsurance payment, please call 1-800-541-2831.


Signed/Sent 6/6/03
Kathryn Kuhmerker
Deputy Commissioner
Office of Medicaid Management

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: