Medicaid Pharmacy Carve-Out Special Edition - Part Two

March 2021
Volume 37 | Number 4

Important:

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 May 1, 2021, Medicaid members enrolled in Managed Care (MC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will receive their pharmacy benefits through the Medicaid Fee-For-Service (FFS) Pharmacy Program instead of through their Medicaid MC Plan. This guidance provides information in addition to what was provided in the Medicaid Update Special Edition – Part One issued Friday, December 18, 2020.

Andrew M. Cuomo
Governor
State of New York

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

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs

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


In this issue …

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Information for Pharmacies

Determining a Member’s Identification Number (ID) and Checking Eligibility

Effective May 1, 2021, each Medicaid MC Plan will implement point-of-service claim denial messaging that directs pharmacies to bill the FFS program where applicable. The member´s Medicaid MC Plan ID Card contains the Client Identification Number (CIN), which is unique to Medicaid members, and should be used to bill FFS. While in some cases the CIN may be embedded in the member's Medicaid MC Plan ID Number, it is always represented in this format: AA11111A. The CIN can be found on both the members Plan ID Card and FFS Client Benefit Identification Card (CBIC).

The chart shown below illustrates where the CIN can be found on each plan ID card, found on the NYS Medicaid MC Pharmacy Benefit Information Center web site. In a future update, NYS DOH will provide the claim denial messaging that will be used by Medicaid MC Plans, starting May 1, 2021.

Medicaid MC ID Card:

Plan Name Member´s Plan ID# is CIN, Embedded in Member´s Plan ID#, or CIN Shown Separately on Plan ID Card
Affinity CIN Shown Separately on Plan ID Card
AmidaCare Member´s Plan ID# is CIN
CDPHP Embedded in Member´s Plan ID#
EmblemHealth Embedded in Member´s Plan ID#
Fidelis CIN Shown Separately on Plan ID Card
Excellus CIN Shown Separately on Plan ID Card
Healthfirst Member´s Plan ID# is CIN
HealthNow Member´s Plan ID# is CIN
HealthPlus Member´s Plan ID# is CIN
Independent Health Embedded in Member´s Plan ID#
Metro Plus Member´s Plan ID# is CIN
Molina Member´s Plan ID# is CIN
MVP CIN Shown Separately on Plan ID Card
United Healthcare CIN Shown Separately on Plan ID Card
VNSNY Choice Member´s Plan ID# is CIN

Pharmacists may also conduct an eligibility check and/or obtain the member´s CIN, by using one of the methods in the chart below. When submitting FFS claims to Medicaid via the NCPDP D.0 format, the Bank Identification Number (BIN) and Processor Control Number (PCN) are required. Specific details can be found in the Medicaid Update Special Edition – Part One , issued Friday, December 18, 2020. Medicaid members may also contact the Medicaid Consumer Helpline by calling (800) 541-2831 to obtain their CIN.

Methods to Check Eligibility or Obtain the CIN:

Method Summary Resources
E 1 Transaction Eligibility Verification
Instructions to complete this transaction begin on page 10 of the resource document provided.
NCPDP D.0 Standard Companion Guide Transaction
ePACES Providers must have an ePACES account and the following information to:
Obtain CIN
  • First and Last Name
  • DOB
  • SSN
  • Gender
Eligibility Verification
  • First and Last Name
  • DOB
  • SSN or CIN
  • Gender
ePACES Login

ePACES MEVS Eligibility Request
Touchtone Telephone Verification System Eligibility Verification
Providers must have the following information:
  • CIN
  • Provider´s National Provider Identifier (NPI) OR MMIS Number
  • Ordering Provider NPI (if applicable)
NYS Program´s MEVS Instructions for Completing a Telephone Transaction

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Identifying Transition Fills

As previously noted, in the December 2020 Special Edition: Part One Medicaid Update, a one-time "transition fill" will be allowed for non-preferred drugs and diabetic supplies. These transition fills can be identified as indicated below. Pharmacists may work with the patient and physician on future prior authorization (PA) requests or, where appropriate, medication changes to preferred options.

  • The eMedNY claims processing system will be populating NCPDP field 548-6F, Approved Message Code, with code "005" - Claim paid under the plan's transition benefit period, otherwise claim would have rejected as prior authorization required.

Billing for Vaccines

As indicated in the Scope of Benefits document, vaccines that are administered by pharmacists are subject to the carve-out and should be billed to FFS. Policy and billing instructions for the administration of COVID-19 vaccines can be found within the NYS Medicaid Coverage Policy and Billing Guidance for the Administration of COVID-19 Vaccines Authorized for Emergency Use guidance. Policy and billing guidance for other vaccines can be found within the NYS Medicaid FFS Program Pharmacists as Immunizers Fact Sheet document.

Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) - Coverage and Billing Guidance

  • The Scope of Benefits document provides a summary of DMEPOS items that are subject to the carve-out. Items that are not subject to the carve-out will remain the responsibility of the MC Plans and are listed in Appendix A of this document.
  • The items subject to the carve out are listed in sections 4.1, 4.2, and 4.3 of the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines and should be billed to FFS. Most items do not require additional authorization prior to dispensing and billing. These items may be dispensed and billed directly to Medicaid.
  • The items in sections 4.4, 4.5, 4.6, and 4.7 of the Durable Medical Equipment, Prosthetics, Orthotics, Supplies and Procedure Codes and Coverage Guidelines document are not subject to the carve-out and should continue to be billed to the member´s MC Plan.
  • There are some DMEPOS items subject to the carve-out, that require pre-approval. To ensure a smooth transition for Medicaid MC Plan members, PA requirements will be temporarily relaxed (e.g. claims will not deny). NYS DOH staff will monitor these claims and outreach to providers to assist them in obtaining the appropriate authorizations for future claims. At a future date, providers will be given notice regarding when PA requirements will commence. For reference, PA instructions may be found within the Appendix A: PA Guidance for DMEPOS section of this issue´s Medicaid Update.

Billing Instructions for DMEPOS

The table below provides billing instructions for DMEPOS items subject to the carve-out.

Claim Format Instructions
NCPDP and 000301 paper claim form When billing electronically for medical supplies:
  • Place procedure code in the National Drug Code (NDC) field with leading zeros. Enter the five-character code from the NYS Medicaid Program Pharmacy Procedure Codes document in the last five spaces of the NDC field.
  • NCPDP Field Names: Product/Service ID- 407-D7 and Product/Service ID Qualifier- 436-E1 (valid values 01=NDC,09= Healthcare Common Procedure Coding System (HCPCS).
  • Items must be billed to Medicaid FFS using the HCPCS code in the DMEPOS Procedure Codes and Coverage Guidelines - (alphanumeric form, example "A4259") should be submitted in the 11-digit NDC field with leading zeros. If providers submit claim using an NDC number, the claim will deny with reject messages indicated below:
      Code Message
    NCPDP Response Code/Message "705" NDC/Antibody Drug Conjugate (ADC) Not Covered
    NCPDP Reject Code "77" Discontinued NDC Number
When billing by paper, refer to the NYS eMedNY Billing Guidelines document.
Professional/ Medical Claim Format 837
Professional 837-P) or paper 150003 form*
When billing by electronic or paper, refer to the NYS 150003 Billing Guidelines - DMEPOS, Orthopedic Footwear, Orthotic and Prosthetic Appliance document.
Point of Service Claims (ePACES) - Real-time DMEPOS claims submissions When submitting claims, refer to the ePACES Professional Real Time Claim Reference Guide.

*Pharmacies that choose to bill via the professional or medical claim format need to have a Medicaid Category of Service (COS) of "0442", assigned to them through the enrollment process.

Brand Less than Generic (BLTG) Program

The BLTG Program initiative promotes the use of certain multi-source brand name drugs when the cost of the brand name drug is less expensive than the generic equivalent. For a current listing of brand name drugs included in the BLTG Program, refer to the most recent program update.

Pharmacies will receive the following denial message when submitting claims for generic drugs in the BLTG program. Denials for generics can be avoided by dispensing the brand name products. A new prescription is not required.

Pharmacy Claim Denial Message:

  Code Message
NCPDP Response Code/Message "421" Dispense Brand Drug Instead of Generic Equivalent
NCPDP Reject Code/Message "78" Cost Exceeds Maximum

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Information for All Providers (Including Pharmacies)

Member Fact Sheet

Please use the Member Fact Sheet found within the Appendix C: Member Fact Sheet) to provide members with the resources and information they need regarding the carve-out. A print-friendly version of the Member Fact Sheet is available in multiple languages on the eMedNY Member Medicaid Pharmacy Benefit web page.

Prescription Limits Change – Duration and Refills

Effective May 1, 2021, prescriptions will be valid and may be filled for up to one year from the date issued. After the prescription expires, a new prescription will be required from the prescriber, even if refills remain on the original prescription. This is a change from the current FFS practice, where prescriptions are valid for only six months and must be filled within 60 days of the date issued.

Updates to the Medicaid FFS Formulary (List of Reimbursable Drugs)

NYS DOH recognizes the need for certain drugs requiring administration by a practitioner to be available through the Medical and Pharmacy Benefit. Such practitioner administered drugs are listed on the eMedNY´s Medicaid Pharmacy List of Reimbursable Drugs and may be billed directly to the FFS program by a pharmacy. Practitioner administered drugs billed as a Medical claim should be billed to the member´s Medicaid MC Plan.

NYS DOH analyzed practitioner administered drugs that are provided as a pharmacy benefit through the Medicaid MC Plans. As a result of this analysis, NYS DOH will add certain practitioner administered drugs to the FFS formulary. These drugs can be found on the NYS DOH List of Physician Administered Drugs Added to the Medicaid List of Reimbursable Drugs document. Practitioner administered drugs dispensed as a Pharmacy Benefit must be delivered by the pharmacy directly to the site of administration. Requirements for delivery can be found on page 7 of the August 2019 Medicaid Update. These requirements ensure proper storage and handling.

Diabetic Supplies

The Scope of Benefits document provides a summary of diabetic supply items that are subject to the carve-out. Diabetic Diagnostics and Daily Care- Glucose Testing Supplies, Disposable Insulin Pumps (Omnipod), Continuous Glucose Monitor (CGM), Insulin Syringes, Needles, Pens, Infusion Supplies, will be transitioned to the FFS program. The FFS program covers all of these items, some of which are part of the Preferred Diabetic Supply Program (PDSP). Items that are not listed on the preferred diabetic supply list are subject to PA.

NYS DOH will allow a one-time transition fill from May 1, 2021, through July 30, 2021, for non-preferred diabetic supplies that are part of the PDSP and will honor PAs already provided by the Medicaid MC Plans.

Over the Counter (OTC) Drugs

There are some NDCs that may have been covered by the Medicaid MC Plans, that are not covered by FFS. However, there are equivalent/comparable NDCs available through FFS. OTC drugs covered by Medicaid FFS can be found on eMedNY´s Medicaid Pharmacy List of Reimbursable Drugs.

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Provider Enrollment

Prescribers

After May 1, 2021, Medicaid FFS will continue to pay for covered products for Medicaid MC members, even for prescribers that have not yet enrolled in the FFS program. However, prescribers should enroll by July 30, 2021, to ensure that they can continue to prescribe for Medicaid members in the future.

Physicians, Nurse Practitioners, or Physician Assistants may use the options below for enrolling as an Ordering Prescribing Referring Attending (OPRA) provider.

  • Enroll quickly online throughout the COVID-19 public health emergency (PHE) through the Provisional Temporary Provider Enrollment (PTPE) portal. Prescribers that choose this option will need to fully enroll as an OPRA provider, within 60 days after the end of the PHE: or,
  • Fully enroll as an OPRA provider using the process described below. While this process takes longer than the PTPE process, no additional enrollment action will be required when the PHE ends.
    • Visit Provider Enrollment & Maintenance.
    • Select Practitioner from the Provider List Filter on the right-hand side of the page.
    • Select provider licensed profession (provider type).

Podiatrists, Dentists, Optometrists, Audiologists, or Certified Nurse Midwives

Podiatrists, Dentists, Optometrists, Audiologists, Certified Nurse Midwives may enroll using the process described below. When using this process, no additional enrollment action will be required when the PHE ends.

  • Visit Provider Enrollment & Maintenance.
  • Select Practitioner from the Provider List Filter on the right-hand side of the page.
  • Select provider licensed profession (provider type).

Full enrollment as a Medicaid FFS billing provider is also an option, for those providers that wish to bill the FFS program for all covered services, in addition to prescribing. Information regarding how to enroll as a Medicaid FFS billing provider can be found on the eMedNY Provider and Maintenance web page. When using this process, no additional enrollment action will be required when the PHE ends.

Pharmacies

Pharmacies not currently enrolled in the FFS program, that wish to continue to service NYS Medicaid MC Plan members, will need to enroll. NYS DOH has updated the Pharmacy Enrollment Policy, found within the Medicaid FFS Pharmacy Manual Policy Guidelines document, which allows enrollment of community-based pharmacies located in New York or in the bordering states (Connecticut, Massachusetts, New Jersey, Pennsylvania and Vermont). The policy also provides a pathway for enrollment for pharmacies servicing NYS Medicaid MC Plan members that are located outside of New York and outside of the bordering states.

During the PHE, pharmacies have the ability to enroll provisionally, where certain enrollment requirements will be waived. Pharmacies that enroll provisionally, will be required to fully enroll 60 days after the end of the PHE.

The following guidance is applicable for pharmacies who choose to submit enrollment applications via the COVID-19 PTPE portal:

  • Pharmacies with the Category of Service (COS) "0441" (Freestanding Pharmacy) or "0442" (Freestanding Pharmacy-Based DME) may now submit enrollment applications through the COVID-19 PTPE portal. Enrolling through this portal allows for a quicker turnaround time.
  • Pharmacies must first create a provider portal account. For instructions on how to create a provider portal account, visit eMedNY´s How to Create Your New eMedNY ID and Log into the COVID-19 PTPE web page. Please note, providers will be required to validate their account with a Verification Code sent to the email used to sign up.

For questions regarding enrolling in the COVID-19 PTPE portal, please contact the eMedNY Call Center at (800) 343-9000 or visit eMedNY´s Pharmacy Carve-Out web page.

DMEPOS Providers

The updated DMEPOS Provider Enrollment Policy can be found within the NYS Medicaid Program Durable Medical Equipment (DME) Manual Policy Guidelines. DMEPOS providers that are located outside New York state may apply for enrollment if they meet the newly established guidelines. DMEPOS providers located in states bordering New York may enroll if they support New York Medicaid members in the common medical marketing area. Out-of-state DMEPOS manufacturers and mail order suppliers may also be considered on a case-by-case basis, as outlined in the NYS Medicaid Program DME Manual Policy Guidelines document.

Information about the DME Supplier application process can be found on the eMedNY Provider Enrollment and Maintenance DME web page.

Physician Dispensers

For the current FFS policy regarding physician dispensers, refer to the Practitioner Dispensing article found within the January 2021 issue of the Medicaid Update. Physicians who are already enrolled in Medicaid FFS as a Physician - Individual Billing Medicaid (Category of Service 0460) or Practitioner Group (Category of Service 0046 or 0090), may apply as a Physician Dispenser, by completing the Request for Dispensing Physicians to Bill Pharmacy Claims form.

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Appendix A: PA Guidance for DMEPOS

DMEPOS billing identifier found in the NYS Medicaid Program DMEPOS Procedure Codes and Coverage Guidelines document.

DMEPOS Billing Resources
HCPCS code is preceded by a pound sign (#).

Prior Authorization

Submitted through the Dispensing Validation System (DVS) through ePACES.
HCPCS Code is underlined.

Prior Authorization

Submitted on paper, by a Health Insurance Portability and Accountab ility Act (HIPAA) 278 transaction or electronically using ePACES.
HCPCS Code is preceded by an asterisk (*)

DiRAD Interactive Voice Response System (IVR)

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Appendix B: Resources

Resources
Topic Description Contact Information Website Links
Claims
Claims Processing for Outpatient Pharmacy Benefits Questions regarding billing and pharmacy claims processing, lost or stolen medications and remittances. eMedNY Support: (800) 343-9000, Option 1 General Information found on the eMedNY web page.

eMedNY Pharmacy Manual.

NYS DOH NCPDP D.0 Standard Companion Guide Transaction Information.
Prior Authorization for Drugs Questions regarding PA or Inquiries about quantity/age/day´s supply and other edits or medication questions. Magellan Clinical Call Center: (877) 309-9493

PA Request Form for Prescriptions.
Magellan Health, Inc.´s NYS Medicaid Pharmacy Program.

Magellan Health, Inc.´s NYS Medicaid Pharmacy Program PDL Listserv email notification sign-up.
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) (DME) Procedures and Supplies Questions regarding PA or Inquiries about quantity/age/d ay´s supply and other edits or medication questions. claims; and hearing aids (800) 342-3005

ohipmedpa@health.ny.gov
eMedNY DME Manual
Carve-Out
Pharmacy Carve-Out Frequently Asked Questions (FAQs) FAQs N/A Transition (Carve-Out) of the Pharmacy Benefit from MC to FFS –FAQs document: https://health.ny.gov/health_care/medicaid/redesign/ mrt2/pharmacy_carve_out/docs/pharm_carve_out_fa q.pdf
Eligibility
Eligibility Verification and ePACES Questions related to ePACES or for assistance with billing and performing MEVS transactions. eMedNY Support:
(800) 343-9000, Option 2

Touchtone Telephone Verification System:
(800) 997-1111
ePACES Help/Log-in

NYS Programs MEVS Instructions for Completing a Telephone Transaction
Members Restricted Recipient Program Providers may direct members requesting a change of pharmacy or provider for restrictions to the OMIG for assistance. Office of the Medicaid Inspector General:
(518) 474-6866
N/A
Policy and Program Information
FFS Preferred Drug List (PDL) The FFS PDL contains a full listing of drugs/classes subject to the NYS Medicaid FFS Pharmacy Programs. Magellan Clinical Call Center:
(877) 309-9493
Magellan Health, Inc.´s NYS Medicaid Pharmacy Program
Medicaid List of Reimbursable Drugs (Formulary) Providers may review the Medicaid Pharmacy List of Reimbursable Drugs for products covered. Questions may be directed to PPNO@health.ny.gov. eMedNY´s Medicaid Pharmacy List of Reimbursable Drugs
Medicaid Pharmacy Program, Policy and Coverage For questions related to the Pharmacy Program, 340B Billing, Drug Pricing, Lost or Stolen Medications, etc. Pharmacy Bureau
(518) 486-3209

PPNO@health.ny.gov
NYS DOH Medicaid Pharmacy Program
Provider Enrollment Provider enrollment, revalidation and NPI termination questions. eMedNY Support:
(800) 343-9000, Option 2 providerenrollment@health.ny.gov
eMedNY´s Provider Enrollment and Maintenance.
Provider Manuals (Physician, Pharmacy, DME, etc.) and Billing Guidelines The Provider Manuals tab has billing and policy related guidance. For example: billing guidelines, procedure codes, fee schedules, etc. for each provider type. N/A eMedNY´s Provider Manuals

eMedNY´s General Billing Guidelines
Training
Provider Outreach and Training Providers may visit the training website to review eMedNY trainings available. N/A eMedNY´s Provider Training

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Appendix C: Member Fact Sheet

Member Fact Sheet

Please use the Member Fact Sheet to provide members with the resources and information they need regarding the carve-out. A print-friendly version of the Member Fact Sheet is available in multiple languages on the eMedNY Member Medicaid Pharmacy Benefit web page.

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Provider Directory

Office of the Medicaid Inspector General:
For suspected fraud or abuse complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit Office of Medicaid Inspector General (OMIG) web site.

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNYwebsite.

Providers wishing to listen to the current week´s check/EFT amounts:
Please call (866) 307-5549 (available Thursday PM for one week for the current week´s amount).

For questions about billing and performing MEVS transactions:
Please call the eMedNY Call Center at (800) 343-9000.

Provider Training:
Please enroll online for a provider seminar here. For individual training requests, call (800) 343-9000.

Beneficiary Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program:
For current information on best practices in pharmacotherapy, please visit the following web sites:

eMedNY
For a number of services, including: change of address, updating an enrollment file due to an ownership change, enrolling another NPI, or revalidating an existing enrollment, please visit eMedNY´s Provider Enrollment page at: https://www.emedny.org/info/ProviderEnrollment/index.aspx, and choose the appropriate link based on provider type.

NY Medicaid Electronic Health Record (EHR) Incentive Program
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.

Comments and Suggestions Regarding This Publication
Please contact the editor, Angela Lince, at medicaidupdate@health.ny.gov.

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