New York State Medicaid Update - March 2019 Volume 35 - Number 4

In this issue …

National Healthcare Decisions Day 2019

National Healthcare Decisions Day (NHDD) is April 16, 2019.

NHDD was created to "inspire, educate, and empower the public and providers about the importance of advance care planning." NHDD in New York is a day dedicated to helping people understand that advance care planning includes much more than filling out forms; it is a process focused first on conversations about your wishes with your loved ones. Everyone has a role to play; families talking with each other about their care preferences and wishes as well as health care providers helping patients to understand how to make sure their wishes are followed in a clinical setting.

Advance care planning is the process of communicating and documenting your wishes for medical treatment in the event you are no longer able to speak for yourself. Through the advance care planning process, you may fill out advance directives or appoint a health care proxy to document your wishes. According to a national survey, ninety percent of people say that talking to their loved ones about end-of-life care is important, yet only twenty-seven percent have actually done so (The Conversation Project National Survey, 2013).

Here are some simple steps to can take to start your advance care planning process:

  1. Think about what matters to you. It can be helpful to prepare yourself before talking to others about advance care planning. Think about what matters most to you and what you value.
  2. Start the conversation. Make time to talk with your loved ones, doctors, or other healthcare professionals about what matters to you and what type of medical treatment you would like if you were unable to speak for yourself. It may take one conversation, or it may take many, but starting the conversation about your wishes is often the hardest part.
  3. Fill out the forms. New York State advance directives include a Health Care Proxy and Medical Orders for Life Sustaining Treatment (MOLST). While everyone over the age of 18 should have a Health Care Proxy, a MOLST may not be appropriate for everyone. Typically, a MOLST is completed for someone with a serious health condition and who:
    • wants to receive or avoid any or all life-sustaining treatment;
    • resides in a long-term care facility or requires long-term care services; and/or
    • may die within the next year.
  4. Review and revise. Advance care planning is a process. You can always update your advance care directives if your preferences have changed. Review the decisions you made periodically and discuss them with your health care proxy and doctors to make sure everyone still understands your wishes.

For more information on advance care planning visit the New York State Department of Health web site at:

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Medicaid Breast Cancer Surgery Centers

Research shows that five-year survival increases for women who have their breast cancer surgery performed at high-volume facilities and by high-volume surgeons. Therefore, it is the policy of New York State Department of Health (the Department) that Medicaid members receive mastectomy and lumpectomy procedures associated with a breast cancer diagnosis, at high-volume facilities defined as averaging 30 or more all-payer surgeries annually over a three-year period. Low-volume facilities will not be reimbursed for breast cancer surgeries provided to Medicaid members.

Each year, the Department reviews the list of low-volume facilities and releases an updated list effective April 1st. The Department has completed its annual review of all-payer breast cancer surgical volumes for 2015 through 2017 using the Statewide Planning and Research Cooperative System (SPARCS) database. Eighty-four low-volume hospitals and ambulatory surgery centers throughout New York State were identified. These facilities have been notified of the restriction effective April 1, 2019. The policy does not restrict a facility's ability to provide diagnostic or excisional biopsies and post-surgical care (chemotherapy, radiation, reconstruction, etc.) for Medicaid members. For mastectomy and lumpectomy procedures related to breast cancer, Medicaid members should be directed to high-volume providers in their area.

The Department will re-examine all-payer SPARCS surgical volumes annually to revise the list of low-volume hospitals and ambulatory surgery centers. The annual review will also allow previously restricted providers meeting the minimum three-year average all-payer volume threshold to provide breast cancer surgery services for Medicaid members.

For more information and to view the list of restricted low-volume facilities, please visit: All questions related to this policy should be directed to the Department at (518) 486–9012.

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C-YES: New York State's Designated Independent Entity for Children's HCBS

Children and Youth Evaluation Service (C-YES) was designated by New York State (NYS) to act as the Independent Entity for children's Home and Community Based Services (HCBS). C-YES is responsible for conducting HCBS eligibility determinations of children prior to their enrollment in Medicaid and serves as the HCBS care coordination alternative to Medicaid-enrolled children/youth who decline Health Home (HH) care management. MAXIMUS Health Services, Inc., is the organization operating C-YES.

Referring a Child who is not Enrolled in Medicaid for HCBS Eligibility Determination

To obtain a Referral Packet, which is used to collect information about the child's medical history and includes consent forms, instructions, and general information about children's HCBS, providers and individuals should call C-YES at: 1-833-333-CYES (1-833-333-2937) or toll-free at 1-888-329-1541.

Upon receipt of a complete Referral Packet, C-YES will:

  • send a Registered Nurse to the child's home or other agreed-upon location to conduct an HCBS eligibility determination;
  • provide Medicaid application assistance to children who are determined eligible for HCBS*;
  • submit Medicaid applications, HCBS eligibility determination outcome and support documents, and capacity updates directly to the Local Department of Social Service (LDSS);
  • develop a person-centered HCBS Plan of Care (POC); and
  • provide education about Health Home care management.

*To access HCBS, NYS must also determine that there is capacity to serve the child and the child must be enrolled in Medicaid.

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New Cycle of the Prevention Agenda Launched

New York State's Prevention Agenda, which began in 2008, has started its third implementation cycle for the period 2019 to 2024. Partnerships between local health departments, health care providers, and community-based organizations are now occurring in every county. Each partnership is addressing health issues selected from the five statewide priority areas:

  • Prevent Chronic Diseases
  • Promote a Healthy and Safe Environment
  • Promote Healthy Women, Infants and Children
  • Promote Well-Being and Prevent Mental and Substance Use Disorders
  • Prevent Communicable Diseases

More information about the Prevention Agenda can be found at: These partnerships welcome new opportunities to engage Medicaid providers in population health efforts. Visitors to the web site can find action plans for each priority along with recommended, evidence-based interventions. The site also links to the award-winning "Prevention Agenda Dashboard" which displays the most current data at the state and local level to track progress in improving health.

New York has made a commitment to be the first age-friendly state in the nation by encouraging interventions that promote healthy aging in people of all ages. The new Prevention Agenda cycle also has a special focus on promoting the Governor's "Health-Across-All-Policies" approach. State agencies are asked to include health considerations in their policies and programs so that New York will become the healthiest state in the nation.

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Opioid Treatment Plan

Effective April 1, 2018, legislation signed by Governor Cuomo with the 2018-2019 State Fiscal Year Budget amends Public Health Law §3331 by adding subparagraph (8), as follows:

8. No opioids shall be prescribed to a patient initiating or being maintained on opioid treatment for pain which has lasted more than three months or past the time of normal tissue healing, unless the medical record contains a written treatment plan that follows generally accepted national professional or governmental guidelines. The requirements of this paragraph shall not apply in the case of patients who are being treated for cancer that is not in remission, who are in hospice or other end-of-life care, or whose pain is being treated as part of palliative care practices.

In short, a written treatment plan in the patient's medical record is required if a practitioner prescribes opioids for pain that has lasted for more than three months or past the time of normal tissue healing. There are exceptions for patients who are being treated for:

  • cancer that is not in remission;
  • hospice or another end-of-life care; and
  • palliative care.

The treatment plan must follow generally accepted national professional or governmental guidelines, and shall include (but is not limited to) the documentation and discussion of the following clinical criteria within the medical record:

  • goals for pain management and functional improvement based on diagnosis, and a discussion on how opioid therapy would be tapered to lower dosages or tapered and discontinued if benefits do not outweigh risks;
  • a review with the patient of the risks of and alternatives to opioid treatment; and
  • an evaluation of risk factors for opioid-related harms.

Such documentation and discussion of the above clinical criteria shall be done, at a minimum, on an annual basis. For an example of a generally accepted national governmental guideline for prescribing opioids for chronic pain from the Centers for Disease Control and Prevention (CDC), visit More information on opioid prescribing in New York State can be found on the Bureau of Narcotic Enforcement web page at:

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New York Medicaid EHR Incentive Program

Distribution to Eligible Professionals & Eligible Hospitals Since the Start of the Program in 2011*
Number of Payments:Distributed Funds:

*As of 3/1/2019

The New York (NY) Medicaid Electronic Health Record (EHR) Incentive Program promotes the transition to EHRs by providing financial incentives to eligible professionals (EPs) and hospitals. Providers who demonstrate Meaningful Use (MU) of their EHR systems are leading the way towards interoperability, which is the ability of healthcare providers to exchange and use patient health records electronically. The goal is to increase patient involvement, reduce costs, and improve health outcomes.

General Announcements

Now Accepting Payment Year 2018 Pre-Validations

Individual and group EPs who have already determined their Medicaid Patient Volume (MPV) may utilize the Pre-Validation services offered by the NY Medicaid EHR Incentive Program. Submitting Pre-Validation enables EPs to submit their data prior to attesting for preliminary review which may subsequently reduce the time of State review.

Please note:

NY Medicaid EHR Incentive Program Support cannot review data until 90 days have passed from the end date of the 90-day MPV Reporting Period. This period is required to allow Medicaid claims to be processed and finalized. Therefore, providers initiating Pre-Validation with an MPV Reporting Period that ended within the last 90 days will receive notice from NY Medicaid EHR Incentive Program support about the inability to review the data. It is recommended to select an MPV Reporting Period using the prior calendar year method. This prevents the possibility of timing out of the twelve months prior to attestation method. Necessary forms for completion can be found as follows:

For more information about Pre-Validation services, please contact

Webinar: Preparing for Payment Year 2019

The Meaningful Use Stage 3 Webinar has been updated to focus on what providers can do now to prepare for Payment Year (PY) 2019. Centers for Medicare and Medicaid Services (CMS) has established eight objectives, each with its own required activity to demonstrate that the EP is meaningfully using Certified Electronic Health Record Technology (CEHRT). CMS calls these activities measures and EPs must either meet the measure(s) for each objective or show that they qualify for an exclusion to the measure. The objectives for Stage 3 are the same as they were for PY 2018, however, some of the measures will change. This webinar will be used as a resource to ensure all providers are prepared for this change. The eight objectives and their measures can be found under the "Meaningful Use Measures" tab on the EHR web site at:

Live Webinar Event: Patient Engagement for Eligible Professionals

Based on feedback received, the NY Medicaid EHR Incentive Program hosted a one-time webinar event on March 12, 2019. This webinar was designed for EPs new to MU. Topics covered included: benefits of the patient portal, strategies and considerations for setting up a portal, and a breakdown of Stage 3 measures involving patient engagement.

MURPH Audit Report Card

The Audit Report Card is a new feature of the Meaningful Use Registration for Public Health (MURPH) System. This is an additional application feature that provides new self-service utility functionality to the MURPH system that provides direct access to MU Public Health On-boarding Statuses for EPs, Eligible Hospitals (EHs) and their representatives. This new feature allows EPs and their representatives quick and easy access to a report of their public health status history for all of the Public Health registries with which they have registered intent to submit data.

For more information visit the MU Public Health Reporting page of the EHR web site at: Questions should be directed to the MU Public Health Reporting Objective Support Team at: 1-877-646-5410, Option 3 (Mon-Fri, 8:30am - 5:00pm) or via e-mail at:

Regional Extension Centers

New York State (NYS) Regional Extension Centers (RECs) offer support to help providers meet their objectives. Answers to questions regarding the program and requirements, assistance on selecting and using CEHRT, or assistance to providers on meeting program objectives is available. NYS RECs offer free assistance for all practices and providers located within New York.

RECs were established nationwide to assist primary care providers in the adoption and meaningful use of EHRs. RECs work to optimize the use of EHRs so that providers can become meaningful users, engage in new health care transformation and quality initiatives, and participate in payment delivery reform programs. NYS has two RECs available to provide support services to healthcare providers as they navigate the EHR adoption process and achievement of MU.

New York City Regional Electronic Adoption Center for Health (NYC REACH)

NYC REACH offers support services to providers located inside the five boroughs of NYC. For more information please visit the NYC REACH web site at: For questions related to NYC REACH please call 1-347-396-4888 or email

New York eHealth Collaborative (NYeC)

NYeC offers support services to providers located outside the five boroughs of NYC. For more information please visit the NYeC web site at: For questions related to NYeC please call 1-646-619-6400 or email

Please Complete the New York Medicaid EHR Incentive Program Customer Satisfaction Survey

Survey responses provide valuable feedback and assist the NY Medicaid EHR Incentive Program in:

  • developing webinars on the Health Information Exchange and the Patient Portal;
  • using the LISTSERV® to send messages that are relevant to EPs (please see details below to subscribe);
  • updating the program web site for ease of use; and
  • hosting targeted training webinars such as the Navigating the EHR Incentive Program Web site webinar to best assist providers.

The NY Medicaid EHR Incentive Program values provider insight. The survey can be found at:

Webinars and Q&A Sessions

A calendar with the date and times of each webinar listed below, as well registration information, can be found at:

EP Stage 3 Meaningful Use

This webinar provides guidance to EPs about the requirements to attest to MU Stage 3 for the NY Medicaid EHR Incentive Program. Topics covered include:

  • Medicaid Eligibility Criteria
  • Brief Overview of the CMS Regulations
  • MU Objectives and Measures
  • Clinical Quality Measures (CQM)

Register at:

Meaningful Use Public Health Reporting

This webinar will provide an in-depth review of the MU Modified Stage 2 and Stage 3 Public Health Reporting Objectives, which are available to EPs. The webinar will also include information on how EPs can meet the Public Health Reporting Objective.

Register at:

Security Risk Analysis (SRA)

This webinar provides guidance to EPs about the SRA requirements to meet MU Objective 1: Protect Patient Health Information. Topics covered include:

  • MU Objective 1: Protect Patient Health Information
  • SRA Toolkit
  • Safety Measures to Consider
  • Common Considerations and Creating an Action Plan

Register at:

NY Medicaid EHR Incentive Program Post-Payment Audit Education Series

NY Medicaid EHR Incentive Program has produced a series of Post-Payment Audit Educational tutorials to help providers to be prepared in the event of a post-payment audit. Links to each of the below tutorials can also be found at:

  • Tutorial 1: Audit Process Overview
  • Tutorial 2: Understanding the Audit Notification Email – Adopt, Implement, Upgrade (AIU)
  • Tutorial 3: Understanding the Audit Notification Email – Meaningful Use
  • Tutorial 4: Completing the Medicaid Patient Volume Spreadsheet
  • Tutorial 5: Submitting Documentation

Visit the Web site

Additional information about the NY Medicaid EHR Incentive Program can be found at: Please use the links provided below to go directly to the web page for the following categories:


The EHR Incentive Program has a dedicated support team ready to assist. Please contact the program at: 1-877-646-5410 (Option 2) or via email at:

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Updated: Credentialed Alcoholism and Substance Abuse Counselor Now Approved for Billing Within an Article 28 Setting for DSRIP Project 3.a.i and Integrated Outpatient Services

Due to an acronym definition error in the February 2019 Medicaid Update, the "PPS" acronym has been corrected to be "Prospective Payment System." All other information herein is the same.

Effective January 1, 2019, an Article 28 facility that has been granted Integrated Outpatient Services (IOS) or Delivery System Reform Incentive Payment (DSRIP) Project 3.a.i authority may bill for services rendered by a Credentialed Alcoholism and Substance Abuse Counselor (CASAC). The CASAC must be properly supervised and medically directed. Clinics may bill for screening, individual and/or group counseling and other services, as applicable. For detailed guidance on permitted CASAC functions, please see the following link:

Federally Qualified Health Centers (FQHCs) that are integrated service providers may bill the Prospective Payment System (PPS) rate for CASAC services. If provided in a group setting, rate code "4011", FQHC Group Psychotherapy, should be billed.

Effective September 1, 2019, CASAC providers rendering services in an Article 28 setting will need their own individual National Provider Identifier (NPI). Until September 1, 2019 CASAC providers may use the Office of Alcoholism and Substance Abuse Services (OASAS) unlicensed practitioner ID number "02249145" consistent with OASAS policy. After September 1, 2019 billing will only be allowed using an NPI assigned to the specific provider rendering the service.


  • Medicaid fee-for-service (FFS) policy questions may be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and Management at (518) 473–2160.
  • Medicaid Managed Care (MMC) general coverage questions may be directed to OHIP Division of Healthcare Planning Contracting and Oversight at(518) 473–1134 or at
  • MMC reimbursement and/or billing requirements questions may be directed to the enrollee's MMC plan. The MMC directory by plan can be found on the New York State Department of Health's web site at:

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Reminder: Reporting of the National Drug Code is Required for all Fee-for-Service Physician-Administered Drugs

As was mentioned in the February 2019 Medicaid Update, effective April 1, 2019, to improve claims accuracy and completeness, an accurate National Drug Code (NDC) must be reported for all physician administered drugs billed on the Institutional claim form. Drugs obtained at the 340B price, indicated by the UD modifier, will also require the NDC. There will be no exceptions to this policy.

The eMedNY billing system will enforce this requirement effective July 1, 2019. This means that starting July 1, 2019, for any physician-administered drug billed under Ambulatory Patient Groups (APG) that does not include an accurate NDC, the line will not pay. Note, all APG fee schedule drugs will still require providers to code the number of units and acquisition cost for the claim line to pay.

Questions regarding Medicaid FFS policy should be directed to the Office of Health Insurance Programs, Division of Program Development and Management at (518) 473-2160. Billing procedure questions should be directed to the eMedNY Call Center at 800-343-9000. Questions regarding Medicaid Managed Care (MMC) policy requirements should be directed to the enrollee's MMC plan.

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Electronic Prescribing: Blanket Waiver for Exceptional Circumstances

The Commissioner of Health has approved a blanket waiver with respect to the electronic prescribing requirements, pursuant to Public Health Law (PHL) § 281 and Education Law § 6810, that go into effect on March 25, 2019, for exceptional circumstances in which electronic prescribing cannot be performed due to limitations in software functionality. The exceptional circumstances for which this waiver applies are set forth below (excerpt of waiver):

The Department recognizes that the standards developed by the National Council for Prescription Drug Programs (NCPDP), as adopted by the Centers for Medicare and Medicaid Services (CMS), still do not address every prescribing scenario. The current standards allow only a limited number of characters in the prescription directions to the patient, including, but not limited to, taper doses, insulin sliding scales, and alternating drug doses.

Similarly, for compound drugs, no unique identifier is available for the entire formulation. Typing the entire compound on one text line may lead to prescribing or dispensing errors, potentially compromising patient safety.

Further, the Department is mindful that practitioners must issue non-patient specific prescriptions in certain instances, and that such prescriptions cannot be properly entered into the electronic prescription software.

For these reasons, pursuant to my authority in PHL § 281(3), I waive the requirements for electronic prescribing in the following exceptional circumstances:

  1. any practitioner prescribing a controlled or non-controlled substance, containing two (2) or more products, which is compounded by a pharmacist;
  2. any practitioner prescribing a controlled or non-controlled substance to be compounded for the direct administration to a patient by parenteral, intravenous, intramuscular, subcutaneous or intraspinal infusion;
  3. any practitioner prescribing a controlled or non-controlled substance that contains long or complicated directions;
  4. any practitioner prescribing a controlled or non-controlled substance that requires a prescription to contain certain elements required by the federal Food and Drug Administration (FDA) that are not able to be accomplished with electronic prescribing;
  5. any practitioner prescribing a controlled or non-controlled substance under approved protocols for expedited partner therapy, collaborative drug therapy management or comprehensive medication management, or in response to a public health emergency that would allow a non-patient specific prescription;
  6. any practitioner issuing a non-patient specific prescription for an opioid antagonist;
  7. any practitioner prescribing a controlled or non-controlled substance under a research protocol;
  8. a pharmacist dispensing controlled and non-controlled substance compounded prescriptions, prescriptions containing long or complicated directions, and prescriptions containing certain elements required by the FDA or any other governmental agency that are not able to be accomplished with electronic prescribing;
  9. a pharmacist dispensing prescriptions issued under a research protocol, or under approved protocols for expedited partner therapy, or for collaborative drug management or comprehensive medication management; and
  10. a pharmacist dispensing non-patient specific prescriptions, including opioid antagonists, or prescriptions issued in response to a declared public health emergency.

This waiver is hereby issued for the ten (10) above-listed exceptional circumstances and shall be effective from March 25, 2019 through March 24, 2020. Before March 25, 2020, I will determine whether the software available for electronic prescribing has sufficient functionality to accommodate each of these exceptional circumstances.

Practitioners issuing prescriptions in all the above-listed exceptional circumstances may use either the Official New York State Prescription Form or issue an oral prescription, provided, however, that oral prescriptions remain subject to PHL §§ 3334 and 3337, which provide for oral prescriptions of controlled substances in emergencies and for other limited purposes, and subject to section 6810 of the Education Law. Pharmacists may continue to dispense prescriptions issued on the Official New York State Prescription Form or oral prescriptions in all of the above-listed exceptional circumstances.

The above blanket waiver shall not affect other general waivers issued to practitioners pursuant to PHL § 281.

(excerpt end)

The full letter as well as additional information regarding e-prescribing can be found on the Bureau of Narcotic Enforcement web page at:

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Reminder: Revalidation of Medicaid Providers is Required

Federal Requirement

Federal regulation 42 CFR (Code of Federal Regulations), Part 455.415, requires that all New York State Medicaid providers must revalidate every five years. Revalidation includes providing information on the provider's ownership, managing employees, agents, persons with a control interest, group affiliations, supervising/collaborating arrangements, as well as providing current addresses, specialties, etc. Providers will be notified by letter when they need to revalidate.

Providers, including prescribers, pharmacies, supervising pharmacists and any other enrolled provider, who do not revalidate will receive a termination letter and will be terminated. Terminated providers will not be able to participate in Medicaid Managed Care (MMC) networks and Children's Health Insurance Program (CHIP), in addition to being unable to bill for fee-for-service (FFS) Medicaid.

Pharmacies will not be able to process claims written by terminated, unenrolled providers. There is no override or exception process available. Information regarding the revalidation process can be found at:

Providers are encouraged to maintain their correspondence address to ensure the letters are sent to the correct address. For questions about the revalidation process or how to maintain ones provider file please visit, contact the eMedNY Call Center at 1-800-343-9000, or email

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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

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs