New York State Medicaid Update - November 2013 Volume 29 - Number 12

In this issue...

Policy and Billing Guidance

Reaching Providers Interactively to Deliver a Safety Message

Single-dose medicine vials are different from multi-dose vials. Know the distinction. Act accordingly.

The New York One & Only Campaign is using cutting-edge public health messaging technology-an interactive infographic-to get that message to health care providers.

Why the "big deal" about single-dose vials vs. multi-dose vials? Well, the Centers for Disease Control and Prevention (CDC) have documented numerous outbreaks of serious disease, both viral and bacterial, due to unsafe injections related to reuse of single-dose vials and misuse of multi-dose vials. In some instances,the disease transmission has led to death. So, knowing how to properly access each kind of vial is crucial for patient safety.

The CDC leads the Safe Injection Practices Coalition's (SIPC) One & Only Campaign, an organization of health-related groups whose mission is to ensure that safe injections are given in all health care settings. Lack of knowledge about correct procedure, recent drug shortages and attempts to save money are among the reasons for the lapses in safe practices.

The SIPC estimates since 2001, more than 150,000 patients have been notified they might be at risk for exposure to hepatitis B virus (HBV), hepatitis C virus (HCV), or human immunodeficiency virus (HIV), via unsafe injection practices.

Those poor practices include using a single-dose vial to treat more than one patient or "pooling" leftover medicine. Single-dose vials typically lack antimicrobial preservatives to protect against bacterial infection. Some practitioners incorrectly access multi-dose vials with used needles or syringes, contaminating the vials for subsequent patients. Multi-dose vials typically contain antimicrobial preservatives-but those preservatives have no effect on bloodborne viruses like HBV, HCV, or HIV.

New York Mediaid Electronic Health Records Incentive Program Update

Click here to see the One & Only Campaign's infographic on a mobile device, a tablet or a desktop computer. With each panel, this information demonstrates to providers, patients, even business managers, that unsafe injections can be costly: first and foremost to patient health, but also potentially to the provider's license, and the medical practice, should an infection be transmitted and a malpractice lawsuit filed. The infographic wraps up with a quick quiz to test learning.

The infographic can also be printed out for distribution at meetings, trainings and in-service events.
NY Medicaid EHR Incentive Program (PDF, 502KB, 1pg.)

Changes in Federal Poverty Levels for Medicaid Presumptive Eligibility Programs

The Affordable Care Act (ACA) has established new Medicaid eligibility income levels. These levels include new Federal Poverty Levels (FPL) percentages for three programs, including the presumptive eligibility component for each; the Family Planning Benefit Program (FPBP), Pregnant Women, and Children under the Age of 19. One notable change is to the FPL for Pregnant Women. Pregnant women will be compared to just one income level, for all services, instead of the two levels used currently.

The new FPLs are listed below:

Federal Poverty Levels for 2014
Family Planning Benefit Program 223%
Pregnant Women 223%
Children Under the Age of 19 154%

The new FPLs should be used when screening for eligibility beginning January 2014. Additional information related to the calculation of an applicant's income will be provided through online provider training.

Fee-for-Service Transportation Management Includes the Offices of Mental Health and People with Developmental Disabilities

Attention: Upstate Medical Providers and Transportation Vendors

Historically, the transportation of enrollees residing upstate whose Medicaid eligibility is with the New York State Office of Mental Health (OMH, county code 97) or Office for People With Developmental Disabilities (OPWDD, county code 98) has been handled in one of two ways:

  • 1. When the cost of transportation is included in the rate paid to a Medicaid program, that program arranges transportation to and from that program; or,
  • 2. When transportation is fee-for-service (FFS), prior authorization is generated by the OMH or OPWDD central office staff located in Albany.

Effective January 1, 2014, the management of FFS transportation for enrollees residing in the following counties will be undertaken by the Department of Health's contracted transportation manager, Medical Answering Services (MAS):

Albany GreeneSt. Lawrence
Cayuga OneidaSchenectady
Chenango LivingstonSchuyler
Columbia OnondagaSullivan
Delaware OrangeUlster
Essex RensselaerWashington
Fulton RocklandWestchester
Herkimer OswegoWayne

For dates of service on or after January 1, 2014, the ordering medical provider must seek authorization from MAS instead of central office staff of OMH or OPWDD. Staff in each agency's Albany-based central office will not process prior authorization requests with service dates on or after January 1, 2014. To secure approval prior to the trip, please call MAS at (866) 932-7740. Trips performed without prior approval from MAS may not be honored.

Ambulance vendors providing emergency transport to these enrollees must seek authorization from MAS for the correct reimbursement within 90 days of the date of service.

Information regarding Medicaid transportation, including required forms and a list of participating transportation vendors, is found online at:

The MAS field liaison is available to discuss the processes for requesting transportation authorization through MAS onsite at each facility. To request an onsite visit, please call MAS at the telephone number above.

Questions? Please contact the Medicaid Transportation Policy Unit at (518) 473-2160 or via e-mail to

Medicaid Pharmacy Prior Authorization Programs Update

Effective December 5, 2013, the fee-for-service (FFS) pharmacy program will implement the following parameters, including 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 September 12, 2013, DURB meeting:

Buprenorphine and Concurrent Opioids

  • Denial of any opioid claim when there is evidence of established oral buprenorphine therapy. Medical necessity rationale for opioid therapy required.

Short-Acting Opioids

  • Duration limit for "opioid naive" patients:
    Fifteen day limit on all initial opioid prescriptions. Prior authorization needed to exceed limit.*


  • * will not apply to patients whose claim history contains a diagnosis of sickle cell disease or cancer.
  • * buprenorphine containing products are not subject to the duration limit.

Systemic Immunomodulators

  • Confirmation of diagnosis for FDA or compendia supported uses. Absence of covered diagnosis in patient's claim history will require prescriber contact with the clinical call center.
  • Step therapy requirement - trial of a disease-modifying anti-rheumatic drug (DMARD) prior to treatment with an immunomodulator (automatic bypass for patients with established immunomodulator therapy).


  • Confirmation of diagnosis for Medicaid covered uses. Absence of covered diagnosis in patient's claim history will require prescriber contact with the clinical call center.

For more detailed information on the above DURB recommendations, please refer to the meeting summary at:

Below 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 the Medicaid FFS Pharmacy Programs:

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

Medicaid enrolled prescribers can also initiate PA requests using a web-based application. PAXpress(r) is a web-based pharmacy PA request/response application accessible through a new button "PAXpress" located on under the MEIPASS button. Additional information, such as the Medicaid Standardized PA form and clinical criteria for the PDP and Clinical Drug Review Program (CDRP), are available on the following websites: or or

Pharmacy Update Dose Optimization Initiative

Effective November 14, 2013, the Medicaid fee-for-service (FFS) program will institute a Dose Optimization initiative. Dose optimization can reduce prescription costs by reducing the number of pills a patient needs to take each day. The NYS Department of Health has identified drugs to be included in this program, the majority of which have FDA approval for once-a-day dosing, have multiple strengths available in correlating increments at similar costs and are currently being utilized above the recommended dosing frequency. Prior authorization (PA) will be required to obtain the following medication beyond the following limits:

Dose Optimization Chart
Angiotensin Receptor Blockers (ARBs)
Brand NameDose Optimization Limitations
Benicar 20mg1 dailyTabletnone
Micardis 20mg, 40mg1 dailyTablet
Diovan 0mg, 80mg, 160mg1 dailyTablet
ARBs/Calcium Channel Blockers
Brand NameDose Optimization Limitations
Exforge 5-160mg1 dailyTabletnone
Brand NameDose Optimization Limitations
Benicar HCT 20-12.5mg1 dailyTabletnone
Diovan HCT 80-12.5mg, 160-12.5mg1 dailyTablet
Edarbyclor 40-12.5mg1 dailyTablet
Micardis HCT 40-12.5mg, 80-12.5mg1 dailyTablet
Beta Blockers
Brand NameDose Optimization Limitations
Bystolic 2.5mg, 5mg, 10mg1 dailyTabletnone
Coreg CR 20mg, 40mg1 dailyTablet
Toprol XL 25mg, 50mg, 100mg1 dailyTablet
HMG Co A Reductase Inhibitors
Brand NameDose Optimization Limitations
Crestor 5mg, 10mg ,20mg1 dailyTabletnone
Central Nervous System
Anticonvulsants - Second Generation
Brand NameDose Optimization Limitations
Lyrica 25mg, 50mg, 75mg, 100mg, 150 mg, 200mg3 dailyCapsule Electronic bypass for diagnosis of seizure disorder identified in medical claims data.
Lyrica 225mg, 300mg2 dailyCapsule
Antipsychotics - Second Generation
Brand NameDose Optimization Limitations
Abilify 2mg4 daily Tabletnone
Abilify 5mg, 10mg, 15mg1 daily Tablet In the case of dose titration for once daily medications, the Department will allow for multi-day dosing (up to 2 doses/daily) for titration purposes for 3 months.
Invega 1.5mg, 3mg1 dailyTablet
Latuda 20mg, 40mg, 60mg1 dailyTablet
Seroquel XR 50mg, 150mg, 200mg 1 dailyTablet
Symbyax 3-25mg, 6-25mg, 12-25mg1 dailyCapsule
Zyprexa Zydis 5mg, 10mg1 dailyTablet
CNS Stimulants
Brand NameDose Optimization Limitations
Concerta ER 18mg, 27mg1 dailyTabletnone
Focalin XR 5mg, 10mg, 15mg, 20mg1 dailyCapsule
Metadate CD 10mg, 20mg1 dailyCapsule
Provigil 100mg1 dailyTablet
Ritalin LA 10mg, 20 mg1 dailyCapsule
Vyvanse 20mg, 30mg1 dailyCapsule
Non Ergot Dopamine Receptor Agonists
Brand NameDose Optimization Limitations
Requip XL 2mg, 4mg, 6mg1 dailyTabletnone
Other Agents for Attention Deficit Hyperactivity Disorder (ADHD)
Brand NameDose Optimization Limitations
Intuniv 1mg, 2mg1 dailyTabletnone
Strattera 40mg1 dailyCapsule
Sedative Hypnotics
Brand NameDose Optimization Limitations
Lunesta 1mg1 dailyTabletnone
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Brand NameDose Optimization Limitations
Effexor XR 37.5mg, 75mg1 dailyCapsule In the case of dose titration for once daily medications, the Department will allow for multi-day dosing (up to 2 doses/daily) for titration purposes for 3 months.
Pristiq ER 50mg1 dailyTablet
Selective Serotonin Reuptake Inhibitors (SSRIs)
Brand NameDose Optimization Limitations
Lexapro 5mg, 10mg1 dailyTablet In the case of dose titration for once daily medications, the Department will allow for multi-day dosing (up to 2 doses/daily) for titration purposes for 3 months.
Viibryd 10mg, 20mg1 dailyTablet
Endocrine & Metabolic
Brand NameDose Optimization Limitations
Januvia 25mg, 50mg1 dailyTabletnone
Onglyza 2.5mg1 dailyTablet
Brand NameDose Optimization Limitations
Actos 15mg1 dailyTabletnone
Actoplus Met XR 15-1000mg1 dailyTablet
Proton Pump Inhibitors
Brand NameDose Optimization Limitations
Dexilant 30mg1 dailyCapsulenone
Nexium 20mg 1 dailyCapsule
Prevacid DR 15mg1 dailyCapsule
Renal and Genitourinary
Urinary Tract Antispasmodics
Brand NameDose Optimization Limitations
Detrol LA 2mg1 dailyCapsulenone
Enablex 7.5mg1 dailyTablet
Toviaz ER 4mg1 dailyTablet
Vesicare 5mg1 dailyTablet
Updated 11/06/13

System messaging has been developed to help guide the pharmacists to appropriately submit the claim or refer to the prescriber. For claims that do not meet the daily dose limit, eMedNY point-of-service (POS) will return a rejected response (NCPDP field 511-FB) "85 - Claim Not Processed," along with additional detailed "75" messages (NCPDP field 526-FQ):

  • 75 A2- Use Higher Strength
  • 75 MD- Duration Criteria Failure**

** Note: This message will display if the claim submitted exceeds a three month titration period.

PA requirements are not dependent on the date a prescription is written. New prescriptions and refills on existing prescriptions require PA even if the prescription was written before the date the drug was determined to require PA. To obtain PA, please contact the PA Clinical Call Center at (877) 309-9493. The clinical call center is available 24 hours per day, 7 days per week. Pharmacy technicians and pharmacists will work with you, or your agent, to quickly obtain PA.

Medicaid enrolled prescribers with an active ePACES account may initiate PA requests through the web-based application PAXpress.(r) The website for PAXpress is available at: https://paxpress.nypa.hidinc.

Mandatory Compliance Program Certification Requirement under 18 NYCRR &521.3(b)


On Sunday December 1, 2013, OMIG will make available on OMIG's website the NYS Social Services Law Compliance Program Certification Form ("Certification Form") for 2013. The 2012 Certification Form for 2012 will remain active on OMIG's website until December 1, 2013 for newly enrolling Medicaid providers.

A webinar on the 2013 Certification Form is available on OMIG's website, at the following link The webinar explains the mandatory compliance obligation, the certification obligation and the form that is to be used starting on December 1, 2013.

The following identifies the Required Providers who must have compliance programs. If you are required to have a compliance program, you are also required to certify on OMIG's website ( that your compliance program meets the requirements of the applicable law and regulations. The certification must occur in December of each year.

Social Services Law & 363-d and Part 521 of Title 18 of the New York State Codes, Rules and Regulations have been actively enforced by OMIG since 2009. Part 521 requires all Required Providers under the Medicaid program that meet the following criteria to certify in December of each year that they have adopted, implemented and maintain 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.

(emphasis added)

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 those subject to the mandatory compliance program obligation to certify to the Department of Health and OMIG that a compliance program meeting the requirements of the regulation is in place.

The regulation, Certification Form, and Frequently Asked Questions ("FAQ's") are available on the OMIG website, on the Compliance landing page at:

It is the responsibility of Required Providers to determine if:

  • a. it has a compliance plan that meets the requirements of SSL &363-d and 18 NYCRR & 521.3 (c); and
  • b. its compliance program is effective.

Additionally, OMIG recommends regular visits to its website to review the information and resources that are published under the Compliance Tab on OMIG's home page. The Compliance Library under the Compliance Tab provides copies of current forms, publications and other resources that could prove helpful in conducting a self-assessment and completing the certification form in December.

OMIG also recommends that Required Providers sign up for e-mail notices from OMIG by subscribing to OMIG's listserv. Anyone can become a subscriber at no cost by signing up on OMIG's home page. The listserv is a great way to keep informed of the introduction of new compliance tools and information on compliance. As additional compliance-related resources are posted by OMIG, those on OMIG's listserv will receive notices of their publication.

If you have any questions, please contact the OMIG's Bureau of Compliance at (518) 408-0401 or by using the Bureau of Compliance's dedicated e-mail address


Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at:

Providers wishing to listen to 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: For individual training requests,
call (800) 343-9000 or e-mail:

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 and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.)

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.

Do you have comments and/or suggestions regarding this publication?
Please contact Kelli Kudlack via e-mail at: