New York State Medicaid Update - March 2021 Volume 37 - Number 3

In this issue …

Reminder: All Providers Serving Children

As a reminder, New York State (NYS) Medicaid-covered children/youth in the care of Voluntary Foster Care Agencies (VFCAs) or placed in foster homes certified by Local Departments of Social Services (LDSS) will be enrolled in Medicaid Managed Care Plans (MMCPs) on or after July 1, 2021, including in Mainstream MMCPs and HIV Special Needs Plans (HIV-SNP), unless they are otherwise excluded or exempt from mandatory Medicaid managed care. Effective July 1, 2021, VFCAs will no longer be payors for services provided to this population; providers will be reimbursed directly by Medicaid fee-for-service (FFS) or the children's/youth's MMCP.

In preparation for this transition, MMCPs will contract with VFCAs as they become licensed to provide a limited set of health-related services to children/youth in their care pursuant to Article 29-I of the NYS Public Health Law. MMCPs are also seeking and offering contracts with community providers with expertise in working with, as well as, treating the foster care population. Pharmacies and other providers serving this population are strongly encouraged to enroll in the NYS Medicaid program and then engage with MMCPs in their area to ensure continued coverage for their members as VFCAs will no longer be the payor for these services after this transition.

All medications and supplies that are not part of the managed care benefit package will be reimbursed under Medicaid FFS, effective July 1, 2021. The Foster Care Pharmacy Carve-Out list will no longer apply. Pharmacies and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPROS) that provide drugs/products to children/youth in the care of VFCAs must enroll in Medicaid FFS prior to July 1, 2021 to be reimbursed by Medicaid FFS for medications, equipment, and supplies provided to this population.

Information and Questions:

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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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NY State of Health: Significant New Tax Credits Available Now to Lower the Cost of Health Coverage

Increased financial assistance is now available to current and new consumers enrolling in a health plan through NY State of Health, the state official health plan marketplace. This financial assistance is being implemented as part of the American Rescue Plan which President Biden recently signed into law. More than 150,000 consumers who are already enrolled in coverage will receive increased tax credits, further lowering their health care costs. In addition, in June 2021, NY State of Health will expand tax credits to tens of thousands of additional New Yorkers with higher incomes who, before the American Rescue Plan, did not qualify for financial assistance. NY State of Health will provide information about the tax credits available to higher income individuals in the coming weeks.

To allow as many consumers as possible to access these enhanced tax credits and, in light of the ongoing public health emergency, the 2021 Open Enrollment Period has been extended through December 31, 2021. Consumers can apply for coverage through the NY State of Health website, by phone at (855) 355‑5777, or by connecting with a free enrollment assistor via the NY State of Health "Find a Broker/Navigator" search tool.

Additional Information:

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Medicaid Consumer Fact Sheets Now Available

New York State Department of Health (DOH) Office of Health Insurance Programs (OHIP) 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. Topics include diabetes, high blood pressure, asthma control, HIV-PrEP (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), and smoking cessation.

Fact sheets can be found on the Medicaid Redesign Team (MRT) II Policies and Guidance web page, available in the following languages: English, Spanish, Traditional Chinese, Russian, Haitian Creole, Bengali and Korean.

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Medicaid Newborn Reporting and Billing Procedures for Hospitals in New York State

As required by Section 366-g of the New York Social Services Law (SSL), hospitals must report live births to the New York State (NYS) Department of Health (DOH) via the newborn reporting system. This system has been active through the local departments of social services since 2001 and statewide through NY State of Health since 2018. Hospitals must report each live birth of a child born to an individual receiving Medicaid to the NYS DOH within five (5) business days of the birth. Failure to report each birth within the established timeframe could result in a financial penalty of up to $3,500, per occurrence.

Establishing Medicaid Coverage for Birthing Individuals and Newborns

Hospitals are required to have procedures in place to correctly capture and report a birthing individuals' Medicaid Client Identification Numbers (CINs). The CIN is the most accurate way for NYS DOH to identify an individual so that their newborn can be added to their Medicaid case. It is important for a birthing individual's demographic information to be reported as precisely as possible. Incorrect information may result in the inability to match the infant to the parent and delay establishing coverage for the newborn. Incorrect reporting of a birthing individual's CIN by a hospital can also cause a Health Insurance Portability and Accountability Act of 1996 (HIPAA) violation when a newborn is added to the wrong Medicaid case. NYS DOH must report all HIPAA violations to the Centers for Medicare and Medicaid Services (CMS) with identified corrective actions for preventing further violations.

A hospital that prematurely opens a newborn's Medicaid case on an NY State of Health account prior to reporting the birth through the NYS DOH automated newborn reporting system risks creating a duplicate CIN for the newborn and assigning incorrect coverage. Hospitals are instructed not to manually add newborns to NY State of Health accounts before the births are reported.

Billing for Hospital Services Provided to Newborns of Birthing Individuals

A hospital is responsible for capturing a birthing individual's correct Medicaid coverage information and billing appropriately. Claims that are billed to and paid Medicaid fee-for-service (FFS) for a newborn when the identified birthing individual is enrolled in a Medicaid Managed Care Plan (MMCP). The birthing individual's MMCP is required to cover the newborn's stay in the hospital. Claims that are billed to and paid by Medicaid FFS for a newborn born to an individual enrolled in an MMCP will be recouped. The hospital must then rebill the MMCP to receive payment.


Questions regarding newborn reporting requirements or newborn enrollment for Medicaid can be emailed to

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Pharmacy Billing Guidance Exceptions for Non-Enrolled Prescribers

New York State (NYS) Medicaid requires enrollment of all licensed providers who serve Medicaid members, including prescribing practitioners identified on pharmacy claims per the Centers for Medicare and Medicaid Services (CMS) and federal regulations. However, under the Medicaid Provider Enrollment Compendium (MPEC) there are two exceptions to the provider enrollment requirement.

1. Interns, Residents and Foreign Physicians in Training — Unlicensed Physicians

In accordance with NYS Education Law Article 131 § 6526, unlicensed physicians who are residents, interns and foreign physicians participating in training programs, are authorized to prescribe. NYS Medicaid recognizes the authority unnder which these unlicensed providers may prescribe; however, these physicians are not eligible for enrollment into the Medicaid program without a license. MPEC allows unlicensed physicians to provide ordering/prescribing/referring/attending services to Medicaid members. The State Medicaid Agency (SMA) is not required to enroll a provider type, such as unlicensed physicians, for the purpose of complying with 42 of the Code of Federal Regulations (CFR) § 455.410(b) or § 455.440, when the provider type is ineligible to enroll in the NYS Medicaid Program.

Guidance and Billing

Additional guidance regarding claim submission for prescriptions written by unlicensed physicians can be found in articles in both the December 2018 and May 2019 issues of the Medicaid Update.


With regard to any claims submitted for a prescription issued to a Medicaid enrollee by any unlicensed prescriber, records should be contemporaneously created and maintained supporting the issuance of such prescription. This requirement applies to all residents, interns and foreign physicians who participate in any medical training program. The documentation must include the National Provider Identifier (NPI) of the Medicaid provider who is responsible for supervising the prescribing unlicensed resident, intern or foreign physician in a training program.

All records related to the issuance of a prescription by non-enrolled prescribers are subject to production upon request by NYS, including but not limited to, by NYS Department of Health (DOH), Office of the Medicaid Inspector General (OMIG), Office of the State Comptroller (OSC) and the NYS Office of the Attorney General.

2. Out-of-State (OOS) Licensed Prescribers

Under federal regulations, all ordering or referring physicians or other professionals (ORPs) must be enrolled in the Medicaid Program. However, the MPEC allows for payment of prescription claims prescribed by OOS licensed physicians or ORPs under limited circumstances.

Please note: The billing guidance below does not apply to out-of-state licensed prescribers that are treating Medicaid members for more than a single instance of emergency care or order within 180 days, or more than one Medicaid member when the services provided are more readily available in another state within 180 days. Federal regulations require NYS Medicaid enrollment for these prescribers.


The following billing guidance applies to OOS licensed prescribers who are either enrolled in Medicare with an "approved" status or are enrolled in their own state's Medicaid plan. The prescription must be for:
  • a single instance of emergency medical care or order for one Medicaid member, or
  • multiple instances of care provided to one Medicaid member when the services provided are more readily available in another state.


  • Pharmacy claims will initially reject for National Council for Prescription Drug Programs (NCPDP) Reject code "56" (Non-Matched Prescriber ID). This means the prescriber is not enrolled in NYS Medicaid.
  • To override above rejection for the OOS prescription situations described above:
    • In Field 439-E4 (Reason for Service Code): enter "PN" (Prescriber Consultation)
    • In Field 441-E6 (Result of Service Code): enter applicable value ("1A", "1B", "1C", "1D", "1E", "1F", "1G", "1H", "1J", "1K", "2A", "2B", "3A", "3B", "3C", "3D", "3E", "3F", "3G", "3H", "3J", "3K", "3M", "3N", "4A")
    • In Field 420-DK (Submission Clarification Code): enter "02" (Other Override)


All questions regarding this policy can be directed to the Medicaid Pharmacy Policy unit at or by calling (518) 486‑3209.

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Medicaid Breast Cancer Surgery Centers

Research shows that five-year survival rates are higher for women who have their breast cancer surgery performed at high-volume facilities. Therefore, it is the policy of New York State (NYS) Department of Health (DOH), that Medicaid members receive mastectomy and lumpectomy procedures associated with a breast cancer diagnosis at high-volume hospitals and ambulatory surgery centers 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, NYS DOH reviews the list of low-volume facilities and releases an updated list effective April 1, 2021. NYS DOH has completed its annual review of all-payer breast cancer surgical volumes for 2017 through 2019 using the Statewide Planning and Research Cooperative System (SPARCS) database. Ninety-six hospitals and ambulatory surgery centers throughout NYS were identified. These facilities have been notified of the restriction effective April 1, 2021. The policy does not restrict a facility’s ability to be reimbursed for providing 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.

NYS DOH will annually re-examine all-payer SPARCS surgical volumes to revise the list of low-volume facilities. The annual review will also allow previously restricted providers meeting the minimum three-year average all-payer volume threshold to be reimbursed for providing breast cancer surgery services for Medicaid members.

Questions and Additional Information:

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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