New York State Medicaid Update - June 2018 Volume 34 - Number 6

In this issue …

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2018-2019 Enacted Budget Initiative: MLTC Partial Capitation Plans Enrollment Lock-In

Beginning December 1, 2018, enrollment into Managed Long Term Care (MLTC) Partial Capitation plans will have enrollment lock-in periods. This applies to those who enroll either by new enrollment or plan-to-plan transfer effective December 1, 2018 or later. These individuals will have a 90-day grace period to elect a plan transfer and then experience a lock-in period for nine months after the end of their grace period (for a total period of one year from the date of enrollment). This will not apply to enrollees that were enrolled in an MLTC partial capitation plan prior to December 1, 2018, unless they elect to transfer to a new MLTC partial capitation plan.

After the initial 90-day grace period, enrollees will have the ability to disenroll or transfer if they can present evidence of good cause. While not an exhaustive list, the following circumstances are examples of good cause: the enrollee is moving from the plan´s service area, the plan fails to furnish services, or it is determined the enrollment was non-consensual. Plans will retain the ability to involuntarily disenroll for the reasons specified in their contract, which includes failure to pay spenddown, hospitalization for greater than 45 days, or the enrollee was absent from the service area for more than 30 consecutive days. After the completion of the lock-in period, an enrollee may transfer without cause, but is subject to a grace period and subsequent lock-in as of the first day of enrollment with the new MLTC partial capitation plan.

This change does not impact a consumer´s ability to enroll into any of the integrated plans: Fully Integrated Duals Advantage (FIDA), Medicaid Advantage Plus (MAP), and the Program of All-Inclusive Care for the Elderly (PACE). Enrollees will have the ability to enroll into an integrated plan at any time, and the integrated plans do not have a lock-in period.

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Regulations for Dental Anesthesia

On December 13, 2016, The New York State Education Department Board of Regents officially adopted new regulations regarding dental anesthesia. The provision of dental anesthesia for date(s) of service on or after July 1, 2017 must be in compliance with the new dental anesthesia definitions, dental anesthesia practice requirements, as well as the new record keeping requirements. The provision of dental anesthesia for date(s) of service on or after January 1, 2018 must comply with the new dental anesthesia certification requirements and the new dental anesthesia education and training requirements. Please keep in mind that the Department of Health maintains the right to "pend" claims and request records for professional review. The associated claims are subject to denial if the records and documentation received are not in compliance with the regulations in effect on the date of service.

The amended regulation can be found here. Questions may be directed to the Bureau of Dental Review at 1-800-342-3005, or by email at

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Harm Reduction Services as a New Medicaid Benefit

Effective July 1, 2018, Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) plans will begin covering harm reduction services (HRS). This change applies to mainstream MMC, HIV Special Needs Plans (HIV SNP) and Health and Recovery Plans (HARP). HRS will be delivered by New York State Department of Health (NYS DOH) authorized and waivered syringe exchange programs (SEP) that are enrolled as Medicaid providers.


HRS originate from the Medicaid Redesign Team (MRT) Health Disparities recommendations to address the public health crisis in opioid use, and the human immunodeficiency virus (HIV) and hepatitis C virus (HCV) epidemics in New York State. HRS target people who use drugs (PWUD) and engage in behaviors that place them at risk for overdose or acquisition of bloodborne diseases. HRS have been shown to reduce such drug-related harms as overdose, drug-related deaths and injuries, and transmission of blood-borne infections such as HIV and HCV.

Scope of Benefit

HRS represent a fully integrated, client-oriented approach to care. HRS must be recommended by a physician or a licensed practitioner and provided by the personnel of a NYS DOH authorized SEP. Services will be provided in accordance with an assessment of care needs and an individualized plan of care created by the SEP. Harm reduction programs provide remedial services for maximum restoration of a beneficiary to his or her best possible functional level.

HRS may be provided without prior authorization. For the first six months commencing July 1, 2018, there will be no limitations on the amount, duration, and scope of these services in MMC. Thereafter, MMC plans, upon receiving Department approval of the plan´s clinical criteria, may conduct concurrent review and retrospective review for medical necessity in accordance with federal regulation, NYS Public Health law, and the MMC/HIV Special Needs Plan/Health and Recovery Plan Model Contract (Model Contract).

HRS do not include syringe exchange, case management activities that are an integral component of other covered Medicaid services, or substance use disorder treatment services. Active referrals to appropriate clinical and supportive services are a critical component of HRS.

Clients may enter HRS via referral from sources such as the SEPs where HRS take place, a health care provider, a managed care plan, a health home, or a substance use disorder treatment program. HRS must be recommended in writing by a physician or other licensed practitioner, who may be internal or external to the SEP where services are provided. Beneficiaries will participate in an initial assessment, and services begin immediately upon assessment.

Medicaid Harm Reduction Billable Services

Development of a Plan of Care through either an initial assessment or a scheduled or event-generated reassessment. A reassessment is a scheduled or event-generated formal re-examination of the client´s situation, functioning, substance use, and medical and psychosocial needs to identify changes which have occurred since the initial or most recent assessment. The reassessment measures progress towards the desired goals and is used to prepare a new or revised harm reduction program plan or confirm that current services remain appropriate. Referrals may be made for behavioral health interventions, support groups, wellness services, substance use disorder (SUD) treatment, and overdose prevention training as needed.

Individual and Group Supportive Counseling assists individuals in understanding how to reduce the behaviors that interfere with their ability to lead healthy, safe lives and to restore them to their best possible functional level. Supportive counseling may be provided to an individual or in a group setting and can cover such topics as: HIV/HCV/Sexually Transmitted Disease (STD) status or substance use disclosure to family members and friends; addressing stigma for drug users in accessing services; maximizing health care services interactions; reducing substance use or using more safely and avoiding overdose; and addressing anxiety, anger, and depressive episodes.

Medication Management and Treatment Adherence Counseling assists clients to recognize the need for medication to address substance use or psychiatric issues, reinforce the importance of adherence to treatment regimens, and identify tools to follow the prescribed regimens. (Medication management does not include the provision of Medication-Assisted Treatment [MAT] services.)

Psychoeducation – Support Groups are stand-alone services that may also be used to supplement individual and/or group supportive counseling. Support groups restore an individual to his or her best possible functional level by focusing on group members´ issues and experiences relative to substance use, finances, medical/health care, support system, incarceration history, and other factors that contribute to risk behaviors for HIV/HCV/STD. Support groups may be facilitated by a direct service provider, a caseworker, or the director of HRS. Groups can also be co-facilitated by a peer.

Billing and Payment

Beginning on July 1, 2018, Medicaid will pay the regionally based rate for their enrollees receiving HRS according to the rate table below.

Harm Reduction Service Description UnitsFFS Rate Code MEDS Category of Service Procedure Codes Provider Specialty Code Upstate Rate per 15 Minutes Downstate Rate per 15 Minutes
Plan of care development, initial assessment 1 unit per 15 minutes per recipient 3146 0265 96150 283 - Counselor $15.99 $22.47
Plan of care development, reassessment 1 unit per 15 minutes per recipient 3146 0265 96151 283 - Counselor $15.99 $22.47
Individual supportive counseling 1 unit per 15 minutes per recipient 3146 0265 96152 283 - Counselor $15.99 $22.47
Medication management and treatment adherence counseling 1 unit per 15 minutes per recipient 3146 0265 H0034 283 - Counselor $15.99 $22.47
Group supportive counseling 1 unit per 15 minutes per recipient 3147 0265 96153 283 - Counselor $2.52 $3.02
Psychoeducation – support groups 1 unit per 15 minutes per recipient 3147 0265 H2027 283 - Counselor $2.52 $3.02

Medicaid Fee-for-Service and Managed Care Billing Instructions

SEPs billing Medicaid FFS and participating with a managed care plan must bill using both 15-minute unit FFS rate codes and managed care procedure codes listed above. Reimbursement will be in accordance with agreements between the provider and the health plan. For two years, beginning July 1, 2018, MMC plans will reimburse HRS at the FFS rate. HRS are a medical benefit to be billed on an institutional claim form.


Questions regarding MMC implementation should be directed to the enrollee´s MMC plan. See also the Department´s MMC guidelines for HRS on the DOH website: /health_care/medicaid/redesign/mrt_8401.

Claiming questions should be directed to the eMedNY Call Center at (800) 343–9000. Policy questions or any additional questions related to the New York State Harm Reduction Benefit may be directed to the NYS Office of Drug User Health at

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Revision in Hepatitis C Prescriber Requirements

In March 2018, Former Governor Cuomo announced the first state-level strategy to end hepatitis C virus (HCV) in New York State (the full announcement can be read here: This strategy includes efforts to increase access to medications and treatment. Consistent with this effort, effective August 1, 2018, the HCV-direct-acting antiviral (DAA) prescriber experience and training clinical criteria (below) implemented by the Medicaid program based on past Drug Utilization Review (DUR) Board action will no longer be required:

  • Require confirmation of prescriber experience and training
  • Prescribed by hepatologist, gastroenterologist, infectious disease specialist, transplant physician or health care practitioner experienced and trained in the treatment of HCV or a healthcare practitioner under the direct supervision of a listed specialist. AND
  • Clinical experience is defined as the management and treatment of at least 10 patients with HCV infection in the last 12 months and at least 10 HCV-related Clinical Medical Education (CME) credits in the last 12 months. OR
  • Management and treatment of HCV infection in partnership (defined as consultation, preceptorship, or via telemedicine) with an experienced HCV provider who meets the above criteria.

In addition, the Department will no longer utilize the Medicaid Hepatitis C Practitioner Information Request Form process and will remove the HCV Approved Practitioners List from the website. As noted in the NYSDOH AIDS Institute HCV Guideline-Treatment of Chronic HCV Infection with Direct Acting Antiviral (, when prescribing HCV antiviral therapy, clinical experience and appropriate continuing education are both important to ensure that HCV medications are prescribed safely and correctly and that all patients receive the highest quality of care.

It is recommended that care providers new to HCV treatment should consult with a liver disease specialist when treating patients with chronic HCV infection and any of the following conditions:

  • Compensated and decompensated cirrhosis
  • Concurrent hepatobiliary conditions
  • Extrahepatic manifestations of HCV, including renal, dermatologic, and rheumatologic manifestations
  • Significant renal impairment (creatinine clearance <30 mL/min) and/or undergoing hemodialysis
  • Active hepatitis B (HBV) infection, defined as HBV surface antigen–positive and detectable HBV DNA
  • Retreatment after any DAA treatment failure

Additionally, providers should refer patients with chronic HCV infection and decompensated liver disease and patients who are pre- or post-transplant to a liver disease specialist. Depending on their level of experience and expertise, care providers may also want to refer patients who have coexisting conditions (including HIV) that require treatment with complex drug regimens to a care provider with experience in the management of complex patients with HCV infection.

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Provider Training Schedule and Registration

Do you have billing questions? Are you new to Medicaid billing? Would you like to learn more about the Electronic Provider Assisted Claim Entry System (ePACES)? If you answered "yes" to any of these questions, consider registering for a Medicaid training session. eMedNY offers various types of educational opportunities to providers and their staff. Training sessions are available at no cost to providers and include information for claim submission, Medicaid Eligibility Verification, the eMedNY website, and ePACES.

Seminars are a valuable opportunity to meet personally with CSRA´s eMedNY Regional Representatives in your area. Seminars are in-person training sessions with groups of providers and billing staff conducted at locations throughout New York State. For seminars offered at a location near you, please check the eMedNY website at:

Webinar Training Also Available. You may also register for a webinar. Webinar training sessions will be conducted online and you will be able to join the meeting from your computer and telephone. After registration is completed, you will receive an email with instructions to join the online meeting and then just log in at the announced time. There is no travel involved. Many sessions offer detailed instruction about Medicaid´s free web-based program ePACES. ePACES allows enrolled providers to submit the following types of transactions:

  • Claims
  • Eligibility Verifications
  • Claim Status Requests
  • Prior Approval/Dispensing Validation System (DVS) Requests

For information on upcoming locations and dates along with fast and easy registration, please visit the eMedNY website here. This website is updated quarterly with new sessions. eMedNY Regional Representatives look forward to having you join them at upcoming training sessions. If you are unable to access the internet to register or have questions about registration, please contact the eMedNY Call Center at (800) 343–9000.

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Breastfeeding Grand Rounds 2018: Increasing Skin-to-Skin Contact to Improve Perinatal Outcomes and Breastfeeding Success

Breastfeeding Grand Rounds (BFGR) is a free, annual webcast sponsored by the University at Albany School of Public Health in partnership with the New York State Department of Health that is available to an international audience. The program draws upon the expertise and experiences of health professionals working in the breastfeeding field to increase the viewer´s knowledge and enhance breastfeeding practices. The 2018 BFGR webcast will include an overview of skin-to-skin contact (Kangaroo Care) for newborns and mothers. Successful strategies, including prenatal education by Women, Infants, and Children (WIC) providers to increase early use and longer duration of skin-to-skin contact for all mothers, will be discussed. Examples from New York, other states, and abroad will be highlighted.

There is a strong evidence base that infants who are held skin-to-skin with their mothers immediately after birth and for the first hours have better cardiorespiratory stabilization, improved thermal protection, and reduced physiological stress. Skin-to-skin contact also fosters neurobehaviors that promote successful breastfeeding, and is associated with increased rates of exclusive breastfeeding and longer duration of breastfeeding. BFGR presenters will explain the neurobehavioral and physiological basis for mother-infant skin-to-skin contact for all newborns. Presenters will identify evidence-based health benefits for infants and mothers from skin-to-skin contact, and how early skin-to-skin contact facilitates breastfeeding success.

Breastfeeding Grand Rounds: Increasing Skin-to-Skin Contact to Improve Perinatal Outcomes and Breastfeeding Success will air on August 2, 2018 from 8:30 a.m. – 10:30 a.m. This webcast is intended for local and state public healthcare professionals and paraprofessionals, clinicians (physicians, midwives, healthcare providers, nurses), and lactation specialists and will offer Continuing Medical Education (CME), Continuing Nursing Education (CNE), Lactation Continuing Education Recognition Points (LCERP), or general continuing education credits. For more information, and to view previous years´ BFGR webcasts, please visit:

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Check out the "What´s New" section on the eMedNY Website

The website has a great resource available called the "What´s New" tab. The first tab on the website lists recent additions and updates to the site, as well as links to the affected sections. This is a great way for providers to keep up to date with items such as:

  • Fee Schedule updates
  • Procedure Code changes
  • Prior Approval Guideline changes
  • And many other changes or additions

Stop by and take a look at the "What´s New" tab and find out all the changes that may have occurred. For older updates, please refer to the archive section and select the desired year. Find out "What´s New" at: Questions? Please contact the eMedNY Call Center at (800) 343–9000.

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NY Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Record (EHR) Incentive Program promotes the transition to EHRs by providing financial incentives to eligible professionals and hospitals. Providers who demonstrate Meaningful Use of their EHR systems are leading the way towards Interoperability, which is the ability for healthcare providers to exchange and use patient health records electronically. The ultimate goal is to increase patient involvement, reduce costs, and improve health outcomes. Since December 2011, over $919 million in incentive funds have been distributed through 34,712 payments to New York State Medicaid providers. Since 2011, Eligible Professionals & Eligible Hospitals have received:

Number of Payments: Distributed Funds:
34,712 $919,602,810

The 2017 attestation period will be opening soon.
Will you be attesting to Modified Stage 2 or Stage 3?
Look below for a quick comparison of the objectives.

Objectives: Modified Stage 2 Objectives: Stage 3 Different What changed
(1) Protect Patient Health Information (1) Protect Patient Health Information NoN/A
(2) Electronic Prescribing (2) Electronic Prescribing Yes Increased Threshold: 1 patient to 5% of Patients
(3) Clinical Decision Support (3) Clinical Decision Support No N/A
(4) Computerized Provider Order Entry (4) Computerized Provider Order Entry Yes Increased Threshold: From 60%/30%/30%, for Measures 1-3, to 60% for All Three Measures
(5) Patient Electronic Access (5) Patient Electronic Access to Health Information Yes Added: Patient Specific Education
(6) Patient Specific Education N/A Yes Incorporated Into: Patient Electronic Access to Health Information
(7) Secure Electronic Messaging (6) Coordination of Care Through Patient Engagement Yes Incorporated Into: Coordination of Care through Patient Engagement
(8) Health Information Exchange (7) Health Information Exchange Yes Added: Medication Reconciliation
(9) Medication Reconciliation N/A Yes Incorporated Into: Health Information Exchange
(10) Public Health Reporting (8) Public Health and Clinical Data Registry Reporting Yes Changes to Available Measures and Corresponding Exclusions

What else can I do to prepare for 2017 Attestation?

Update your registration for Public Health Reporting on the Meaningful Use Registration for Public Health (MURPH) application here.

  • Make sure that any changes to your personal information have been updated at:
    • Centers for Medicare and Medicaid Services (CMS)
    • eMedNY
  • Attend the Modified Stage 2 or Stage 3 webinar for more information on the above objectives.

Visit Our Website

Information Includes the following and much more:

Listserv – Have program announcements sent right to your inbox!

The NY Medicaid EHR Incentive Program publishes listserv messages each month, and additional messages when there are important changes to the program that will impact eligible providers. In the listserv you will find:

  • Updates regarding the NY Medicaid EHR Incentive Program Administration
  • Attestation system (MEIPASS) announcements and updates
  • Attestation dates and deadlines
  • Current quarter webinar schedule
  • Program requirements
  • Links to training resources and tutorials
  • CMS final rule releases and programmatic changes


To register for the NY Medicaid EHR Incentive Program listserv, send an email to: In the body of the message enter: SUBSCRIBE EHR_INCENTIVE-L Your Name. For example: SUBSCRIBE EHR_INCENTIVE-L John Doe

You can also register for the MU Public Health Reporting listserv for information on the Public Health Reporting Objective for the EHR Incentive Program, Send an email to In the body of the message enter: SUBSCRIBE PUBLIC_HEALTH-L your name. For example: SUBSCRIBE PUBLIC_HEALTH-L Jane Doe

Attend Webinars

The NY Medicaid EHR Incentive Program hosts webinars and we have several sessions over the next couple of months that are focused on preparing for payment year 2018. To sign up for the webinars and additional information, please visit our webinar calendar here: /health_care/medicaid/redesign/ehr/calendar/.

phone icon Questions? We have a dedicated support team ready to assist. Contact us at 877-646-5410, option 2 or

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

Andrew M. Cuomo
Former Governor
State of New York

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

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs