New York State Medicaid Update - January 2021 Volume 37 - Number 01

In this issue …

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.

Important Information for All Providers Serving Children

Effective July 1, 2021, as part of the New York State overall redesign of children's healthcare and behavioral health systems, Medicaid-covered children/youth in foster care will be enrolled in Medicaid Managed Care Plans (MMCP) unless they are otherwise excluded or exempt from mandatory Medicaid managed care. The Medicaid-covered children/youth in foster care can either be in the care of Voluntary Foster Care Agencies (VFCAs) or be in foster homes certified by Local Departments of Social Services (LDSS) statewide. Their enrollment in MMCP can include Mainstream MMCP and HIV Special Needs Plans (HIV-SNP).

Beginning in February 2021, the State will license qualified VFCAs pursuant to Article 29-I of the New York State Public Health Law (visit: for Laws of New York, then select "PBH" for Public Health, then navigate to Article 29-I) to deliver a limited set of health-related services to children/youth in their care. In accordance with the 29-I Health Facility Billing Guidance, Medicaid will cover health and behavioral health services provided to eligible children/youth by licensed 29-I Health Facilities. Effective July 1, 2021, MMC Plans will begin covering 29-I Health Facility services for their eligible members.

Effective February 1, 2021, the Medicaid fee-for-service (FFS) Program will update the Medicaid Foster Care Drug Carve-Out List with additional drug(s)/drug classes and products listed on the Preferred Diabetic Supply Program. VFCAs will continue to cover the cost of drugs/products that are not included on the Foster Care Drug Carve-Out list until June 30, 2021. Effective July 1, 2021, all pharmacy benefits for this population will be paid for under Medicaid FFS.

All providers who deliver services to children/youth in foster care or to children/youth in the care of VFCAs should be aware of this transition. Effective July 1, 2021, VFCAs will no longer be the payor for Medicaid covered services delivered to children/youth in their care, and community providers serving these children will direct claims to the child/youth's MMCP or the Medicaid FFS, as applicable. To avoid disruption in services to children/youth during this transition, providers traditionally serving this population are strongly encouraged to enroll in the NYS Medicaid program then engage with MMCP in their area to ensure continued coverage for their patients.

Policy requirements for this transition, including continuity of care requirements for transitioning children/youth enrolling in Medicaid managed care, 29-I Health Facility rate information, and 29-I Health Facility services guidelines, can be located on the Department of Health's 29-I Health Facility (VFCA Transition) web page.


All questions may be directed to

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Help Stop the Spread of COVID-19 by Sharing the COVID Alert NY App

New York State Department of Health's COVID Alert NY app is gaining participation with more New Yorkers every day. Please keep sharing the COVID Alert NY app information with partners and consumers. Together everyone can help stop the spread of this virus.

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Medicaid Consumer Fact Sheets Now Available

New York State Department of Health (DOH) Office of Health Insurance Programs has created Medicaid consumer fact sheets focused on chronic health conditions. Each fact sheet provides information regarding how a condition can be prevented and managed, as well as relevant Medicaid benefits that can be used to help enrollees stay healthy. Fact sheets are currently available on the topics of diabetes, high blood pressure, asthma control and HIV-PrEP (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), in the following languages: English, Spanish, Traditional Chinese, Russian, Haitian Creole, Bengali and Korean. Fact sheets on additional health topics will be produced in the coming weeks and will be posted on the Medicaid Redesign Team (MRT) II Policies and Guidance web page.

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Reminder: Sign Up for eMedNY Training Webinars

eMedNY offers a number of training webinars for providers and their billing staff. Webinars are conducted online, so that providers may join the meeting via a computer and telephone. No travel is necessary.

Valuable provider webinars offered include:

  • ePACES for Dental, DME, Free-Standing and Hospital-Based Clinics, Home Health, Institutional, Nursing Home, Physician, Private Duty Nursing, Professional (Real-Time), Transportation and Vision Care
  • ePACES for Dispensing Validation System (DVS) for Durable Medical Equipment (DME)
  • ePACES for Dispensing Validation System (DVS) for Rehabilitation Services
  • eMedNY Website Review
  • Medicaid Eligibility Verification System (MEVS)
  • New Provider / New Biller

Webinar registration is fast and easy. To register, view the list of topics, descriptions and available session dates, please visit the Provider Training web page. Providers are reminded to review the webinar descriptions carefully to identify the webinar appropriate for their specific training needs.

Questions regarding training webinars should be directed to the eMedNY Call Center at (800) 343‑9000.

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Change of Address (and Contact) Notification

Providers must notify Medicaid of any change of address, telephone number, or other pertinent information within 15 days of the change. eMedNY distributes provider checks and paper remittances using the Pay-To Address kept on file. Other mail, including important updates, is directed to the Correspondence Address kept on file for providers. Providers may be missing out on important notifications if their address on file is outdated. Occasionally, eMedNY provider representatives will need to contact providers by telephone with important information that may impact claims processing and payment.

To update provider addresses and telephone information, providers must complete their designated Change of Address form. Each Change of Address form contains detailed instructions for submission based on provider type and license/registration address.

Change of Address forms can be completed online using the fillable option or printed. Providers must sign using their original signature in ink without using white out, red ink or double-sided forms. Both forms must be mailed to:

P.O. Box 4610
Rensselaer, NY 12144-4610


All questions may be directed to the eMedNY Call Center at (800) 343‑9000.

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NY State of Health Open Enrollment for New Yorkers Extended Through March 31

NY State of Health's 2021 Open Enrollment Period will be extended through March 31, 2021 as New Yorkers can apply for coverage through NY State of Health, New York's health insurance Marketplace, or directly through insurers.

Extending the Open Enrollment Period to March 31, 2021 helps to align New York with the federal Public Health Emergency which was recently extended to April 20, 2021. This extension allows individuals enrolling in Qualified Health Plan coverage additional time to enroll for coverage in 2021 and means that enrollment remains open for all NY State of Health programs, which is especially important during the ongoing public health emergency.

Individuals who are eligible for other NY State of Health programs – Medicaid, Essential Plan and Child Health Plus – can enroll year-round. As always, consumers can apply for coverage through the NY State of Health website, by phone at (855) 355‑5777, and by connecting with a free enrollment assistor.

Additional information on NY State of Health insurance options during the Coronavirus emergency can be found at the NY State of Health Coronavirus (COVID-19) Information web page.

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Medicaid Pharmacy Prior Authorization Programs Update

On November 5, 2020, the New York State Medicaid Drug Utilization Review Board (DURB) recommended changes to the Medicaid pharmacy prior authorization (PA) programs. Effective February 4, 2021, the fee-for-service (FFS) PA requirements will change for management of acute pain.

Prior Authorization in the Management of Acute Pain

For opioid-naïve patients, PA is required when initiating therapy with a short-acting opioid (SAO) at equal to or greater than (≥) 50 morphine milligram equivalents (MME) per day. Patients with a cancer or sickle cell disease diagnosis, or who are in hospice care, will not require PA.

Additional Information:

  • Providers can visit the DURB web page for detailed information regarding this update.
  • Providers can refer to the Preferred Drug List (PDL) for updated information, as well as a full listing of drugs subject to the Medicaid FFS Pharmacy Programs.
  • Providers and their agents can quickly obtain a PA by contacting the clinical call center at (877) 309–9493. The clinical call center is available 24 hours per day, seven days per week with pharmacy technicians and pharmacists available to assist providers.
  • Medicaid enrolled prescribers can also initiate PA requests using a web-based application. PAXpress® is a web-based pharmacy PA request/response application accessible through the "PAXpress" web button located on under the "MEIPASS" section.
  • Providers can refer to the following web sites for additional information:

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Practitioner Dispensing


The State Fiscal Year (SFY) 2021-22 enacted budget delays the transition of the Medicaid Pharmacy benefit to the Medicaid Fee-for-Service (FFS) Pharmacy Program by two years, until April 1, 2023.

Effective April 1, 2021, in concert with the Pharmacy Transition, the New York (NY) Medicaid Pharmacy Fee-for-Service (FFS) program will enable claims submission for drugs dispensed by practitioners authorized to prescribe, in accordance with NY State Education Law Article 137 §6807(1)(b) and (2)(a) and Public Health Law §2312. The laws can be found at Laws of New York, then by selecting "EDN" or "PBH" for the respective laws and navigating to correct articles and sections. This is referred to as practitioner dispensing, which provides the ability for practitioners to dispense certain medications to their patients.

NY FFS Medicaid will reimburse practitioners under the following parameters:

  • to supply antibiotics (to treat Chlamydia and other Sexually Transmitted Infections) to a patient for later use by the patient and/or the patient's sexual partners. [Public Health Law §2312]
  • pursuant to NY Education Law, NY licensed practitioners authorized to prescribe may dispense up to a 72-hour supply, or more than 72-hour supply when:
    • practicing in hospitals as defined in section twenty-eight hundred one of the Public Health Law;
    • the dispensing of drugs is at no charge to their patients;
    • their practices are situated ten miles or more from a registered pharmacy;
    • the dispensing of drugs is in a clinic, infirmary or health service that is operated by or affiliated with a post-secondary institution;
    • the dispensing of drugs is due to a medical emergency as defined in NY State Education Law Article 137 §6810(6);
    • the dispensing of drugs that are diluted, reconstituted or compounded by a prescriber;
    • the dispensing of allergenic extracts; or
    • the dispensing of drugs pursuant to an oncological or acquired immunodeficiency syndrome (AIDS) protocol:
      • An oncologic protocol is written set of instructions to guide the administration chemotherapy, immunotherapy, hormone therapy, targeted therapy to patients for the treatment of cancer or tumors. It does not include protocols that cover drugs prescribed to relieve side effects of these therapies or to relieve distressing symptoms (such as nausea or pain). [Education Law §6807]
      • An AIDS protocol is a written set of instructions to guide the administration antiretroviral drugs to patients for the treatment of HIV infections or AIDS. It does not include protocols that cover medications prescribed to provide relieve side effects of these therapies or distressing symptoms (such as nausea or pain). [Education Law §6807]

Additional Information and Questions:

  • Information regarding how to enroll in Medicaid FFS as a practitioner dispenser and billing guidance will be published in a subsequent issue of the Medicaid Update.
  • Questions regarding this policy should be directed to the Medicaid Pharmacy Policy unit by emailing or by calling (518) 486–3209.

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Updated Coverage Criteria for Healthcare Common Procedure Coding System Code E0467: Home Ventilator, Multi-Function Respiratory Device

For dates of service on or after February 1, 2021, the Coverage Criteria for Healthcare Common Procedure Coding System (HCPCS) code "E0467" have been updated. Providers can refer to the DME Provider Communication: Updated Coverage Criteria for HCPCS Code E0467- Home Ventilator, Multi-Function Respiratory Device document for more information.


  • For policy questions, providers can contact the Bureau of Medical review at (800) 342‑3005 or email
  • All Medicaid Managed Care (MMC) questions regarding policy should be directed to the member's MMC plan.

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Dental Procedure Code Changes Effective January 1, 2021

Effective January 1, 2021, the dental procedure code "D9920" Behavior Management code has been deleted and is not billable for dates of service after January 1, 2021. A new procedure code of "D9997" has been added.

"D9997" Dental Case Management Code

The new procedure code "D9997" is for individuals with special health care needs. Individuals, with physical, medical, developmental or cognitive conditions resulting in substantial functional limitations that require modification in the delivery of comprehensive oral health care services, need special treatment considerations.

The new code criteria will be as follows:

  • This per visit incentive is meant to compensate for the greater knowledge, skill, sophisticated equipment, extra time and personnel required to treat these individuals.
  • The fee will be paid in addition to the normal fees for specific dental procedures.
  • For purposes of the NYS Medicaid program, this code is limited to those who receive ongoing services from community programs operated or certified by New York State Office for People with Developmental Disabilities (OPWDD). These individuals have a recipient exception code of "RE 81" [Traumatic Brain Injury (TBI) Eligible] or "RE 95" (OPWDD/Managed Care Exemption).
  • This code can also be used for individuals for which the provider has a "Medical Immobilization/Protective Stabilization (MIPS)" form from institutions only.
  • This code is not billable in conjunction with "D9430" or procedures performed under deep sedation/general anesthesia. In this situation, a report is not required.
  • The code "D9997" reimburses at $29.00 in NY Medicaid fee-for-service (FFS).

Additional Information and Questions:

  • When billing, providers are advised to use the procedure code that was active on the date the service was rendered. The code "D9920" is valid if services were performed prior to January 1, 2021.
  • Please direct all questions to

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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