New York State Medicaid Update - December 2013 Volume 29 - Number 14

In this issue...

Policy and Billing Guidance

New Medicaid Provider Outreach, Education and Support Services for Electronic Health Records Adoption and Meaningful Use

The NYS Medicaid EHR Incentive Program and New York's two Regional Extension Centers (RECs), the New York eHealth Collaborative (NYeC) and NYC REACH (Regional Electronic Adoption Center for Health), have launched a new initiative that will provide outreach, technical, and support services for Medicaid providers. Providers who were previously ineligible to receive direct support from a REC for earlier Meaningful Use initiatives (offered and funded via the Office of the National Coordinator for Health IT) are now eligible for additional funding via the federal HITECH grant for support services to adopt, implement or upgrade certified EHR technology and reach Meaningful Use Stage1.

Specialists as well as Primary Care Practitioners are encouraged to enroll. Participation in this program provides direct assistance to providers to qualify for Medicaid EHR Incentive payments up to $63,750 per eligible provider. Eligible Medicaid Provider categories:

  • Specialist Physicians (M.D. and D.O.); Dentists; Nurse Practitioners; Certified Nurse-Midwives;
  • Pediatricians**; Physicians Assistants (PA): If a FQHC or RHC is led by a PA, that PA and all other PAs who practice at the FQHC/RHC are eligible; and
  • Primary Care Physicians that were excluded from previous REC programs.

The program is open to both Medicaid Managed Care and fee-for-service (FFS) providers. In order to receive EHR Incentive Program payments, providers within these categories must be enrolled as a New York Medicaid fee-for-service (FFS) provider and meet the Medicaid patient volume threshold (30% Medicaid encounters: individual or group, **20% for pediatricians). For more information on qualifications and enrollment:

Providers that practice outside of New York City should contact Peggy Frizzell, HIT Implementation Project Manager for NYeC, via e-mail at or by phone at (646) 619-6562.

Providers that practice within New York City should contact NYC REACH at or by phone at (347) 396-4888.

Enrollment capacity is limited and the program grant ends July 31, 2014, so please reach out as soon as possible to take advantage of this time sensitive funding opportunity!

Medicaid Payment Schedule for the Upcoming Holidays

Provider payments (EFTs and checks) will be released one day later than the usual Wednesday release due to the upcoming Christmas and New Year's Day Holidays. Payment release for these weeks will be as follows:

  • Payments issued on Monday 12/9/2013 (Cycle 1894) will be released on Thursday 12/26/2013 and;
  • Payments issued on 12/16/2013 (Cycle 1895) will be released on Thursday 1/2/2014.

Discontinuance of the Family Health Plus Program (FHPlus)

New York State will cease accepting applications for the Family Health Plus (FHPlus) program after December 31, 2013. Anyone who submits an application prior to, or on that date and are found eligible, will be enrolled in FHPlus. Effective January 1, 2014, new applications will be evaluated using MAGI (modified adjusted gross income) eligibility rules, and if eligible, applicants will be enrolled in Medicaid Managed Care.

Effective January 1, 2014, single individuals and childless couples who are currently enrolled in FHPlus will be moved to Medicaid Managed Care. For other FHPlus participants (parents and 19 & 20 year olds living with their parents), eligibility will be redetermined at renewal, and if income is at or below 138% of the FPL (150% for 19 &20 year olds living with their parents), the individuals will be transitioned to Medicaid Managed Care. Recipients with income over 138% of the FPL but at or below 150% Federal Poverty Level (FPL), may be eligible for premium assistance for a Silver-rated qualified health plan, and will be instructed to apply through the New York State of Health (Marketplace).

When transitioning FHPlus recipients to Medicaid Managed Care, the individual will remain in the same plan if Medicaid Managed Care is available. If an enrollee is in a plan that does not have a Medicaid Managed Care plan, the individual will receive full coverage fee-for-service until a plan is selected or the individual is assigned to a plan.

For any questions, please contact the Office of Health Insurance Programs at (518) 473-6397.

Presumptive Eligibility for the Family Planning Benefit Program (FPBP)

Presumptive eligibility (PE) for the FPBP provides immediate Medicaid coverage for family planning services to individuals screened eligible pending a full eligibility determination. Applicants for presumptive eligibility may attest to their current residency, household size, income, citizenship/immigration status, and identity.

Last year, program changes were implemented for the Family Planning Benefit Program and providers who wanted to perform PE duties had to have a signed Memorandum of Understanding (MOU) with the New York State Department of Health (NYSDOH). At that time, providers who had an existing MOU with a local department of social services (LDSS) or the Human Resource Administration (HRA) were offered the opportunity to sign a new MOU with NYSDOH. We are now offering this opportunity to all Medicaid enrolled family planning service providers.

Once an MOU is jointly signed, provider staff performing PE screenings and/or providing application assistance for the FPBP, must complete mandatory training, now available online (link below) and sign confidentiality agreements. For more information regarding how this PE process works, please see the November 2012 issue of the Medicaid Update.

If you have any questions about the MOU process, or would like an MOU sent to you, please contact Megan Gagliardi by phone at (518) 473-6397, or by e-mail at We look forward to working with you.

NCPDP D.0 Billing Requirements for Medicare Pharmacy Claims

The following information must be completed on claims for beneficiaries that are eligible for both Medicare and Medicaid (dual eligible):

Medicare Part B Crossover Claims

  • Enter the Medicare Part B carrier number in field 340-7C "Other Payor ID" to identify the payer as Medicare Part B.
  • Enter a value of "05" in field 339-6C 'Other Payor ID Qualifier" to identify Medicare Part B carrier number.
  • Patient Responsibility Amounts for Deductible and/or Coinsurance must be reported. To report Patient Responsibility Amounts for Deductible and/or Coinsurance enter the information noted below into fields 351-NP (Other Payer Patient Responsibility Amount Qualifier) and field 352-NQ (Other Payer Patient Responsibility Amount):
  • 351-NP- Enter "01" Qualifies Deductible reported in field 352-NQ.
    352-NQ- Enter Deductible Amount.
  • 351-NP- Enter "07" Qualifies Coinsurance Amount
    352-NQ - Enter Coinsurance Amount

Note: Medicaid will pay the Medicare deductible on claims where Medicare is the primary payer.

  • When Medicare's payment exceeds the Medicaid fee, Medicaid will pay 20% of the Medicare coinsurance amount due. This is considered payment in full and the provider cannot bill the beneficiary for any remaining balance.
  • When Medicare's payment is less than or equal to the Medicaid fee, Medicaid will pay the full Medicare coinsurance.
  • With Medicaid/Medicare crossover claims, for claims that would have required Medicaid prior approval, prior approval is not required since Medicare approved and paid for the primary claim.
  • Medicaid does not reimburse for any Medicare Part D co-payments.

Third Party or Medicare Managed Care

  • Enter a value of '99' in field 340-7C "Other Payer ID" to identify the payer as Commercial Payers (TPL) or a value of "13" to identify the payor as Medicare Managed Care.
  • Enter a value of "99" in field 339-6C "other payor ID qualifier" to identify Medicare Managed Care or Commercial Insurance (TPL).
  • Patient Responsibility Amounts for Deductible, Coinsurance and/or Co-Payment must be reported. To report Patient Responsibility Amounts for Deductible, Coinsurance and/or Co-Payment enter the information noted below into fields 351-NP (Other Payor Patient Responsibility Amount Qualifier) and field 352-NQ (Other Payor Patient Responsibility Amount):
  • 351-NP- Enter "01" Qualifies Deductible reported in field 352-NQ.
    352-NQ- Enter Deductible Amount.
  • 351-NP- Enter "05" Qualifies Co-Payment Amount reported in field 352-NQ.
    352-NQ- Enter Co-Payment Amount.
  • 351-NP- Enter "07" Qualifies Coinsurance Amount reported in field 352-NQ.
    352-NQ- Enter Coinsurance Amount.
  • Enter appropriate "Other Coverage Code" in field 308-C8 (values shown below) and "Other Payor Amount Paid" in field 431-DV as applicable.
  • The values for Other Coverage Code are: 0 = Not Specified
    1 = No Other Coverage Identified
    2 = Other Coverage Exists - Payment Collected
    3 = Other Coverage Exists - This Claim Not Covered
    4 = Other Coverage Exists - Payment Not Collected

Note: The Other Payer Amount Paid Field 431-DV is an optional field and should not be submitted unless the member has other drug coverage and you have received reimbursement (i.e. Other Coverage Code value of "2") or been notified that the service is not covered by the other insurance company (i.e., Other Coverage Code value of "3").

Additional information on billing can be found in the Pro-DUR ECCA Provider Manual available online at

Notice to Medicaid Beneficiaries Regarding Medicaid Coverage of Orthopedic Footwear and Compression Stockings

On December 9, 2013, Judge Charles J. Siragusa ruled that the limitations on medically necessary orthopedic footwear and compression stockings applied as a result of April 1, 2011 amendments to New York Soc. Serv. Law § 365-a(2)(g)(iii) and (iv) can no longer be applied in Medicaid coverage determinations. (Davis v. Shah, W.D.N.Y., 12-CV-6134).

Effective December 9, 2013, the Medicaid program is returning to medical necessity criteria applied prior to the April 1, 2011 State law amendments.

  • The criteria for coverage of medically necessary prescription footwear, shoe modifications and additions is no longer limited to diabetics, children under the age of 21, or for use as part of a lower limb brace.
  • The criteria for coverage of medically necessary compression and support stockings coverage is no longer limited to use during pregnancy or for treatment of open venous stasis ulcers.

For additional information please refer to the Provider Communication "Medicaid Prescription Footwear and Stocking Benefit Update" located in the DME manual at

Increased Frequency Limits for Smoking Cessation Counseling (SCC)

Effective January 1, 2014, Medicaid fee-for-service (FFS) expands the frequency of smoking cessation counseling (SCC) coverage for all Medicaid eligible recipients, including pregnant women. In accordance with Section 4107 of the Patient Protection and Affordable Care Act (ACA), current coverage of smoking cessation counseling services will be modified to include a maximum of two quit attempts per 12 months, which will include up to four face-to-face counseling sessions per quit attempt, thus increasing the limits on SCC from 6 to 8 per 12 months. SCC when provided to pregnant women, including both counseling and pharmacotherapy, will not include cost sharing. Providers must follow eMedNY billing guidelines to ensure that pregnant women are exempt from cost sharing.

This policy will be implemented by Medicaid managed care and Family Health Plus plans effective March 1, 2014.

For more information regarding the smoking cessation counseling benefit, please refer to the April 2011 Medicaid Update, which provides a comprehensive summary of SCC policy and billing guidelines.

Questions regarding Medicaid Managed Care or Family Health Plus should be directed to the enrollee's Medicaid Managed Care or Family Health Plus plan. Questions regarding FFS coverage of SCC billing may be directed to the eMedNY Call Center at (800) 343-9000 and policy questions to the Division of Program Development and Management at (518) 473-2160.


Pharmacists as Immunizers Vaccine for Children Program Reminder

Vaccines for individuals under the age of 19 are provided free of charge by the Vaccines for Children (VFC) program. Medicaid FFS WILL NOT reimburse providers for vaccines for individuals under the age of 19 when available through the VFC program.

Providers have an obligation to participate in VFC if they want to offer vaccinations to patients less than 19 years of age. Pharmacists are only permitted to vaccinate those 18 years of age and older. The only VFC eligible children that pharmacists can currently vaccinate are those who are 18 years old. Although pharmacies are not required to join the VFC program when limiting their vaccine administrations to beneficiaries 19 and older, please remember that during times of flu season, the Governor may issue an executive order allowing pharmacies to immunize patients less than 19 years of age. Vaccine administration for the VFC population is at an enhanced reimbursement fee of $17.85. By not enrolling in the VFC program, these pharmacies will not be able to administer to this population.

Billing Instructions:

Providers must submit via NCPDP D.0, in the Claim Segment field 436-E1 (Product/Service ID Qualifier), a value of "09" (HCPCS), which qualifies the code submitted in field 407-D7 (Product/Service ID) as a Procedure Code. Lastly, in field 407-D7 (Product/Service ID), enter the Procedure code. Providers may submit up to 4 claim lines with one transaction. For example, providers may submit one claim line with the Procedure Code 90656 (Influenza Virus Vaccine), and another claim line for Procedure Code 90460 (VFC Immunization Administration through 18 years of age). For administration (through 18 years of age) of multiple VFC vaccines on the same date, code 90460 should be used for each vaccine administered.

For VFC enrollment information, go to:

For the Medicaid Fee for Service Pharmacists as Immunizers Fact Sheet, go to:

Further questions regarding Medicaid reimbursement of immunizations may be directed to the Medicaid Pharmacy Program at (518) 486-3209 or via e-mail to:

Additional information on influenza can be found at NYS Department of Health's website at:

Change in Coverage of Barbiturates for Dual Eligible Population

Effective January 1, 2014, Medicare Part D prescription drug plans and Medicare Advantage Prescription Drug Contracting (MAPD) plans will be required to cover barbiturates for ALL medically accepted indications.

Only drugs that are excluded by law from being covered by the Medicare Part D plans, such as certain prescription vitamins and over-the-counter drugs, are covered by NYS Medicaid for dual eligibles (Medicare/Medicaid). As a result, effective January 1, 2014, NYS Medicaid will no longer provide dual eligibles with coverage of barbiturates.

NYS Medicaid continues to cover barbiturates for NYS Medicaid beneficiaries who are not Medicare eligible.


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


Medicaid Required Providers (as described below) are required to implement and maintain a compliance program as described in NYS Social Services Law Section 363-d and 18 NYCRR Part 521.3(c). Any Required Provider must also certify annually that its compliance program meets the statutory and regulatory requirements. The certification must occur in December of each year.

OMIG reminds all those who must have a compliance program that they must complete the certification on OMIG's website ( by December 31, 2013.

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

The following identifies the Required Providers that must have compliance programs.

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. OMIG may also refer matters to other investigatory agencies. 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.

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 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.

As always, Medicaid providers have an independent obligation to be aware of existing statutory and regulatory requirements of the Medicaid program. 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 regarding New York State's mandatory compliance obligation for Medicaid providers, 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:

EHR Incentive Update

NY Medicaid EHR Incentive Program (PDF, 559KB, 1pg.)