New York State Medicaid Update - January 2017 Volume 33 - Number 1

In this issue …

Reminder from the Office of the Medicaid Inspector General (OMIG) Regarding the Managed Care Annual Program Integrity Report

This is a reminder to all Managed Care Organizations subject to the requirements of the March 1, 2014 Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Model Contract that the 2016 Annual Program Integrity Report (Report) is due and must be submitted by January 31, 2017.

The Report will only be accepted electronically and must be submitted securely. Additional information, as well as a link to submit the reports, is posted on OMIG's website under the "Resources" tab on the homepage.

The Report form is available on the Office of the Medicaid Inspector General's (OMIG) website at:

Reporting Instructions may be accessed at:

Additional guidance can be found at:

Questions regarding the report may be directed to

Transgender Related Care and Services Update

This article updates the June 2015 Medicaid Update article titled, "New York State Medicaid Updates Regulations" and the May 2016 Medicaid Update article titled, "Transgender Related Care and Services Update."

Medicaid regulations at 18 NYCRR 505.2(l), relating to Medicaid coverage for transgender care and services, were amended on August 31, 2016 and again on December 7, 2016.

Gender Reassignment Surgery

  1. One of the prerequisites for Medicaid coverage of gender reassignment surgery is that the individual have letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for surgery. One letter must be written by a New York State licensed psychiatrist, psychologist, psychiatric nurse practitioner, or licensed clinical social worker who has an ongoing relationship with the patient. (The December 7, 2016 amendment to the regulation added licensed clinical social workers to this list.) The second letter may be written by a New York State licensed psychiatrist, psychologist, physician, psychiatric nurse practitioner, or licensed clinical social worker working within their scope of practice. The recommendation for surgery in each letter must be based on an independent assessment/evaluation of the individual.
  2. The revised regulations provide that the following gender reassignment surgeries, services, and procedures are available, based on a determination of medical necessity by a qualified medical professional:
    • mastectomy, hysterectomy, salpingectomy, oophorectomy, vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, penectomy, orchiectomy, vaginoplasty, labiaplasty, clitoroplasty, and/or placement of a testicular prosthesis and penile prosthesis;
    • breast augmentation, provided that: the individual has completed a minimum of 24 months of hormone therapy, during which time breast growth has been negligible; or hormone therapy is medically contraindicated; or the patient is otherwise unable to take hormones; and
    • electrolysis when required for vaginoplasty or phalloplasty.
    The above services are available under fee-for-service (FFS) Medicaid without prior approval. With respect to Medicaid Managed Care (MMC) enrollees, administrative prior authorization requirements may be applied; however, the MMC Plan must accept the qualified medical professional's determination of medical necessity.
    Any other surgeries, services, and procedures in connection with gender reassignment not listed above, or to be performed in situations not described above, including those done to change the patient's physical appearance to more closely conform secondary sex characteristics to those of the patient's identified gender, will be covered if it is demonstrated that such surgery, service, or procedure is medically necessary to treat a particular patient's gender dysphoria, and prior approval is received. Coverage is not available for surgeries, services, or procedures that are purely cosmetic, i.e., that enhance a patient's appearance but are not medically necessary to treat the patient's underlying gender dysphoria.
  3. Although the minimum age for Medicaid coverage of gender reassignment surgery is generally 18 years of age, the revised regulations allow for coverage for individuals under 18 in specific cases if medical necessity is demonstrated and prior approval is received.

For complete billing guidance for gender reassignment surgery, please see the Physician-Surgery Provider Manual at:

Medicaid Coverage of Pubertal Suppressants and Cross-sex Hormones

In accordance with the revised regulations, Medicaid FFS and MMC plans will provide reimbursement for medically necessary hormone therapy for treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, will be covered as follows:

  1. Treatment with gonadotropin-releasing hormone agents (pubertal suppressants), based upon a determination by a qualified medical professional that an individual is eligible and ready for such treatment, i.e., that the individual:
    1. Meets the criteria for a diagnosis of gender dysphoria;
    2. Has experienced puberty to at least Tanner stage 2, and pubertal changes have resulted in an increase in gender dysphoria;
    3. Does not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment;
    4. Has adequate psychological and social support during treatment; and
    5. Demonstrates knowledge and understanding of the expected outcomes of treatment with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment.
  2. Treatment with cross-sex hormones, including testosterone cypionate, conjugated estrogen, and estradiol, for patients who are 16 years of age or older, based upon a determination of medical necessity made by a qualified professional; patients who are under 18 years of age must meet the applicable criteria listed in paragraph 1 above. Payment for cross-sex hormones treatment for a patient who is under 16 years of age and who otherwise meets these requirements will be made in specific cases if medical necessity is demonstrated by a qualified medical professional and prior approval is received.

For questions regarding Medicaid FFS policy, providers should contact the Division of Program Development and Management at (518) 473–2160 . For questions regarding MMC, providers should contact the enrollee's MMC plan directly for implementation details.

Issuance of IRS Form 1099

CSRA, eMedNY contractor for the Department of Health, issues IRS (Internal Revenue Service) Form 1099 to providers at the beginning of each year for the previous year's Medicaid payments. The 1099s are issued with the individual provider's social security number or for businesses, with the Federal Employer Identification Number (FEIN) registered with NY Medicaid.

As with previous years, please note that the IRS 1099 amount is not based on the date of the checks/electronic funds transfer (EFT); rather, it is based on the date the checks/EFTs were released to providers. Subsequently, due to the two-week check lag between the date of the check/EFT and the date the check/EFT is issued, the IRS 1099 amount will not correspond to the sum of all checks/EFTs issued for your provider identification number during the calendar year.

The IRS 1099 that will be issued for the tax year 2016 will include the following: Check/EFT dated 12/21/15 (Cycle 2000) released on 01/06/2016 through, Check/EFT dated 12/12/16 (Cycle 2051) released 12/28/16.

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

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

Please note that 1099s are not issued to providers whose yearly payments are less than $600.00. IRS 1099s for the year 2016 were mailed prior to January 31, 2017. The above information is provided to assist providers with reconciling the IRS 1099 amount. Any questions should be directed to the eMedNY Call Center at: (800) 343–9000 .

Short Video On Appropriate Antibiotic Usage Could Save You Time This Cold & Flu Season

During busy cold and flu season, healthcare providers often tell the NY "Get Smart (Know When Antibiotics Work) Campaign" that some patients demand antibiotics for upper respiratory infections (URIs).

While a provider knows that antibiotics don't work for most URIs, which are largely viral in nature (i.e. the common cold, influenza, or bronchitis), they do experience what is sometimes perceived as pressure from patients to prescribe antibiotics, although studies indicate that might not be the case. Patients may just want a conversation about antibiotics.1, 2

Still, some providers are convinced if they don't prescribe the antibiotics, the patient will go to another provider who will. This frustrates many providers because they know prescribing antibiotics when they will not be effective increases the global health threat of antibiotic resistance.

Adding to the problem, providers may have limited time and are not able to give a long explanation about antibiotic resistance. Sometimes it may be easier to prescribe the antibiotic even though the provider knows it is not an effective course.

What's an evidence-based time-saver that could help? The New York State Department of Health/Get Smart video, "Educating Patients About Antibiotic Usage," gives providers strategies for communicating with patients about why antibiotics aren't always the answer. The video shows providers how to explain antibiotic resistance, give patients advice on symptomatic relief for viral infections,3 and set up a contingency plan4 if the patient doesn't get better in a few days. And it can all be said in just one minute – it's been timed!

Follow this link to see the video: The NY "Get Smart Campaign" is funded by a grant from the Centers for Disease Control and Prevention (CDC).

1 Mangione-Smith R, McGlynn EA, Elliott MN. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics. 1999;103:711-8

2 N, et al. What parents think about antibiotics for their child's acute respiratory tract infection. Poster presented at: IDWeek, October 7-11, 2015, San Diego, CA

3 Mangione-Smith R, Zhou C, Robinson JD, et al. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med 2015;13:221-7

4 Mangione-Smith R, McGlynn EA, Elliott MN. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001;155:800-806

NY Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Record (EHR) Incentive Program provides financial incentives to Eligible Professionals (EP) and hospitals to promote the transition to EHRs. Providers who practice using EHRs are in the forefront of improving quality, reducing costs and addressing health disparities. Since December 2011 over $783 million in incentive funds have been distributed within 24,495 payments to New York State Medicaid providers.


Million Paid

Are you eligible? For more information, visit

New Informational Website

In December 2016, the NY Medicaid EHR Incentive Program launched a new informational website. The new website includes detailed program information on all of the prior and current Meaningful Use (MU) stages, program requirements, guidance for the public health reporting objective, and also has a more comprehensive section for post-payment audit guidance. Please visit the new website at:

MEIPASS Availability

The NY Medicaid EHR Incentive Program Administrative Support Service (MEIPASS) is currently closed due to important maintenance being performed on the system for Meaningful Use (MU) attestations for payment year 2015 and beyond. Program support will continue to be available by phone at 877-646-5410.

We thank you for your patience. Launch of the new MEIPASS system has been delayed due to issues found during testing. We want to make sure that the system operates smoothly for the provider community and for our team at the Department of Health. Please sign up for our LISTSERV to receive notification about when attestations will start being accepted again.

Preparing to Attest

Visit to register for the program.

Verify your system is complete and certified at: on the Certified Health IT Product List.

Utilize NY Medicaid EHR Incentive Program support services:

  • Numerator Request: EPs may request a summary of their Medicaid claims as guidance for calculating Medicaid patient volume.
  • Pre-validation: Individual and group EPs who have already determined their Medicaid patient volume may submit data to NY Medicaid prior to attesting.

Questions? Contact NY Medicaid EHR Incentive Program Support at:

Need Assistance?

In addition to the NY Medicaid EHR Incentive Program Support Team, who can be reached via phone at 877-646-5410 or via email at:, there are two Regional Extension Centers available to assist you.

EPs in New York City can contact NYC REACH at 347-396-4888 or

EPs outside of New York City can contact NYeC at 646-619-6400 or

Questions? Contact for program clarifications and details.

Mandatory Pharmacy Controlled Substance Fact Sheet

Pursuant to Chapter 71 of the Laws of 2016, Part D, Section 1, new educational materials were developed by the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and the New York State Department of Health (DOH) to assist pharmacies with required educational efforts.

Effective October 22, 2016, pharmacies registered in New York State are required to distribute, at the time of dispensing any prescribed drug that is a controlled substance, the Important Facts About Controlled Substance Prescription Medications fact sheet which includes the dangers of misuse and the potential risk for addiction, the warning signs of addiction, alcohol and drug addiction treatment resources, and proper disposal guidelines. Pharmacies may choose to provide additional information and may distribute the information through electronic means, if the consumer opts to receive information electronically.

The Important Facts About Controlled Substance Prescription Medications fact sheet is available to download and/or order at the New York State Office of Alcoholism and Substance Abuse Services website at:, or the New York State Bureau of Narcotic Enforcement website at: Additional brochures and posters are available on these websites as resources.

For further information, please contact OASAS at: or by calling 518-473-3460.

The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
State of New York

Howard A. Zucker, M.D., J.D.
New York State Department of Health

Jason A. Helgerson
Medicaid Director
Office of Health Insurance Programs