New York State Medicaid Update - October 2022 Volume 38 - Number 12

In this issue …


Attention Practitioners: eMedNY Provider Enrollment Portal Offers New Function, Active October 5, 2022

All actively enrolled New York State (NYS) Medicaid practitioners can now update expiring license data in the Provider Enrollment Portal ("Portal"). Upon notification of an upcoming license expiration, practitioners can log into the Portal to view their license information. If needed, the license end date can be updated, and a copy of the professional license renewal can be uploaded. Practitioners who have been notified that their license will expire or have been terminated due to an expired license, can update their license or reactivate their enrollment via the Portal. Practitioners are encouraged to visit the eMedNY "How Do I" web page, for more information.

The ability to update a license in the Portal adds to a growing list of maintenance transactions currently available for practitioners, such as the ability to:

  • view individual provider data in real time including Electronic Transmitter Identification Numbers (ETINs);
  • submit address changes;
  • perform Drug Enforcement Administration (DEA) updates;
  • affiliate individual providers to groups;
  • add any Medicaid provider specialty [examples include physician and dental specialties, diabetes and asthma educator, and/or Medicaid Obstetrical and Maternal Services (MOMS)];
  • update electronic funds transfer (EFT) information; and
  • check the status of maintenance transactions.

Portal Training Opportunities

The Portal provides step-by-step instructions to guide practitioners through the accurate completion of transactions. Practitioners are strongly encouraged to attend a live training webinar to learn more about the latest Portal functions and features, including but not limited to:

  • Initial Log-In/Account Creation;
  • Multi-Factor Authentication (MFA)/Security Protocol;
  • Provider Enrollment Portal Overview;
  • Dashboard Functions; and
  • Provider Profile Functions.

Register for a live training webinar
eMedNY offers live training webinars on a reoccurring basis. To view the training schedule and register for training, practitioners can visit the eMedNY "Provider Training" web page.

View a recorded training webinar
To view a recording of the official eMedNY Provider Enrollment Portal webinar, practitioners can visit the eMedNY "Provider Training Videos" web page.

The Future of the Portal

Upcoming portal functions such as the ability for enrolled practitioners to add categories of service and the ability for other provider types to update expiring licenses, are forthcoming. Portal development is a complex undertaking involving many stakeholders. As soon as a functionality is developed and successfully tested, communications are issued, and the function is released. This process will be continuous until all provider enrollment activities are completed in the Portal.

Questions

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

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Medicaid Fee-for-Service Guidance for New York State Indian Health Service Providers

The New York State (NYS) Department of Health (DOH) reimburses Tribal Clinics designated as an Indian Health Service (IHS) providers based on an All-Inclusive Rate (AIR), in accordance with State Plan Amendment (SPA) #99-39. SPA #99-39 requires Tribal 638 outpatient facilities to be paid using the outpatient per visit rate. IHS clinics are reimbursed at an all-inclusive threshold rate for all medical or behavioral health services provided to NYS Medicaid members during qualifying threshold visits. The all-inclusive threshold rate includes all facility and professional fees associated with the services rendered. Providers can refer to the Federal Register notice, published on April 8, 2022 by the Indian Health Service, for more information.

All medical services provided in a tribal clinic rendered to NYS Medicaid fee-for-service (FFS) members should be billed to NYS Medicaid using the all-inclusive "1610" threshold rate code. It is advised to use AIR code "1610" for services rendered to both American Indians/American Natives (AIs/ANs) and non-AIs/ANs. For all services rendered by clinics licensed by the NYS Office of Mental Health (OMH) or NYS Office of Addiction Services and Supports (OASAS) to NYS Medicaid FFS members, use the following all-inclusive rate codes:

  • "1907" - OMH (AIR)
  • "1908" - OASAS (AIR)

Please note: The Saint Regis Mohawk Tribe is currently the only tribe assigned OMH and OASAS rate codes.

All medical and behavioral health services rendered by federally recognized tribal clinics designated as IHS providers are exempt from the Ambulatory Patient Group (APG) reimbursement methodology and are reimbursed via the federal AIR. Services provided by the following practitioners/programs qualify as IHS threshold visits and meet the requirements for payment of the AIR:

  • Physicians;
  • Physician Assistants (PAs);
  • Nurse Practitioners (NPs);
  • Licensed Midwives (LMs);
  • Licensed Clinical Social Workers (LCSWs)/Licensed Master Social Workers (LMSWs);
  • Dentists/Dental Hygienists;
  • Psychologists;
  • Optometrist/Opticians;
  • Physical Therapists (PTs)/Occupational Therapists (OTs)/Speech-Language Pathologists (SLPs);
  • Podiatrists;
  • Registered Dietitians, Registered Nurses (RNs), Pharmacists, Respiratory Therapists [AIR reimbursement limited to only those providing diabetes self-management training (DSMT) and asthma self-management training (ASMT)];
  • OMH Article 31 Licensed Clinics;
  • OASAS Article 32 Certified Outpatient Programs; and
  • OASAS Article 32 Opioid Treatment Programs.

Please note: If a NYS Medicaid member is seen for both medical and behavioral health services on the same date of service, two separate claims may be billed one for the medical services with rate code “1610” and a second claim for the behavioral health services using the appropriate OMH/OASAS rate codes shown above.

Medicaid Managed Care (MMC) Plans are required to pay IHS providers at least the federal AIR for all qualifying threshold visits for both AIs/ANs and non-AIs/ANs. MMC Plans have been directed to identify all claims that were reimbursed at less than the IHS AIR that require an adjustment and to automatically reprocess claims to pay the full AIR retroactively back to April 1, 2020.

The eMedNY system has been modified to reimburse all Medicaid FFS IHS claims to the federal AIR. Additionally, effective April 1, 2020, all MMC Plans are required to pay IHS providers their applicable encounter rate published annually in the Federal Register by the IHS. Effective April 1, 2020, tribal IHS clinics no longer need to submit Medicaid FFS claims (rate code “7827”) to seek supplemental wrap payments under the Supplemental Payment Program, as MMC Plans are required to pay the full federal AIR. To ensure that tribal IHS clinics have been properly paid, DOH will systematically identify any FFS claims with service dates on or after April 1, 2020, that were reimbursed less than the IHS AIR and will automatically reprocess those claims to pay the full AIR. IHS providers do not need to resubmit any claims.

Questions and Additional Information:

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Applied Behavior Analysis Service Updates

Effective January 1, 2023, New York State (NYS) Medicaid Managed Care (MMC) Plans will cover Applied Behavior Analysis (ABA) services for MMC enrollees. ABA providers offering services to a MMC enrollee must contact the enrollees specific MMC Plan(s) for coverage, billing, and reimbursement guidance. An MMC Plan directory can be found in the Information for All Providers – Managed Care Information manual.

Effective April 1, 2022, the NYS Medicaid fee-for-service (FFS) program increased the fee of reimbursement for ABA services from $7.25 per 15-minute unit ($29.00/hour) to $19.07 per 15-minute unit ($76.28/hour). Claims for NYS Medicaid FFS enrolled ABA providers submitted on or after April 1, 2022, will be automatically reprocessed to reflect this increased fee. The NYS Medicaid Applied Behavioral Analysis Services Fee Schedule has been updated to reflect this fee increase.

NYS Medicaid FFS has removed the 60-minute per date of service minimum requirement for billing ABA services. NYS Medicaid FFS will reimburse enrolled Licensed Behavior Analysts (LBAs) for ABA services provided by LBA limited permit holders under their supervision.

NYS Medicaid FFS has added the following Current Procedural Terminology (CPT) codes to the ABA Fee Schedule:

CPT Code CPT Code Description
97156 Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes.

*CPT code "97158" is effective for dates of service on or after November 1, 2022. CPT code "97158" will be reimbursed at $3.28 (per unit, per member) in a group setting of no more than eight individuals.

The New York State Medicaid Fee-For-Service Program – Licensed Behavior Analysts & Certified Behavior Analyst Assistants Policy Manual for Providing Applied Behavior Analyst Services has been updated.

Questions and Additional Information:

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Update on Coordination of Benefits Submissions for Medicaid Fee-for-Service Pharmacy Billing

Effective November 1, 2022, the New York State (NYS) Department of Health (DOH) will strengthen current system editing to further ensure appropriate submission of NYS Medicaid fee-for-service (FFS) pharmacy claims when the patient has other third-party coverage. These changes will recognize all values in specified fields and will reject or approve, per program policy, when other patient responsibility amounts are accepted and and other third-party insurance billing is validated when the claim is not covered. This is an update to previous guidance on this topic issued in the following Medicaid Update issues:

Coordination of Benefits (COB) ensures the correct party pays first. NYS Medicaid is always the payor of last resort; federal regulations require that all other available resources be used before NYS Medicaid considers payment. If there is a responsible third-party that should be paying for the health benefits of the patient such as a health insurance provider, the responsible third-party should pay first. NYS Medicaid pays the lesser of Patient Responsibility (PR) or the NYS Medicaid fee, regardless of the PR amount. For pharmacies, this rule applies to all PR, which includes deductible, co-insurance, copay, and other patient responsibility.

Effective November 1, 2022, NYS Medicaid will not accept a combination of Other Coverage Code of "3" in National Council for Prescription Drug Program (NCPDP) field 308-C8 (Other Coverage Code) with any reject code in field 472-6E when another third party is responsible for payment. The pre-adjudication edit will be expanded for this field and will return the NCPDP Reject Code (DE 3988) (6E - M/I Other Payer Reject Code).

The provider must work with the primary insurance to obtain coverage for the member. This could involve prior authorization (PA) requirements, appeal processes, or changes to medications ordered to align with the primary plan formulary products, etc. Providers should refer to the Reminder: Pharmacy Billing for Medicaid Patients with other Coverage article published in the November 2021 issue of the Medicaid Update, for more information regarding this topic. If all attempts for coverage have been exhausted and coverage has not been granted from the primary insurer, NYS DOH may consider the denial under special circumstances. The medication in question would still be subject to any editing requirements under the NYS Medicaid FFS program. Submitting Third Party Liability (TPL) -covered claims that incorrectly bypass the TPL Plan responsibility of payment is considered inaccurate billing and may be subject to audit recoveries.

Questions and Additional Information:

  • All questions regarding this update should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
  • FFS claim questions, COB billing questions, or any billing issue should be directed to the eMedNY Call Center at (800) 343-9000.

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Medicaid Pharmacy Prior Authorization Programs Update

On July 14, 2022, the New York State (NYS) Medicaid Drug Utilization Review (DUR) Board recommended changes to the NYS Medicaid pharmacy prior authorization (PA) programs. The Commissioner of Health has reviewed the recommendations of the DUR Board and has approved changes to the Preferred Drug Program (PDP) within the fee-for-service (FFS) pharmacy program. Effective November 17, 2022, PA requirements will change for some drugs in the following PDP classes:

  • Antipsychotics, injectable
  • Antipsychotics, 2nd generation
  • Other Agents for Attention Deficit Hyperactivity Disorder (ADHD)
  • Immunomodulators, Systemic
  • Glucagon Agents-NEW CLASS

Effective November 17, 2022, criteria for Immunomodulators, Systemic, Aducanumab-avwa (Adulhelm®), botulinum toxins, infliximab (Remicade®) and its biosimilars, as well as vedolizumab (Entyvio®), will be added as follows.

Immunomodulators and Systemic

Step therapy (ST):

  • Trial of a disease-modifying anti-rheumatic drug (DMARD) prior to treatment with an immunomodulator for indications not specified below.
  • Trial of a tumor necrosis factor (TNF) inhibitor prior to treatment with a Janus kinase (JAK) inhibitor for indications not specified below.

Indication-specific requirements:

  • Asthma (history and concurrent use of a corticosteroid).
  • Nasal polyps (history and concurrent use of an intranasal corticosteroid).
  • Atopic dermatitis (Trial with a topical prescription product for a duration of at least three months.
    • For JAK inhibitors: Trial of topical prescription product and systemic product for a combined duration of at least six months.

Aducanumab-avwa (Aduhelm®)

Recommendation 1
Before initiating aducanumab-avwa (Aduhelm®), prescribers must attest that the patient has been diagnosed with mild cognitive impairment due to Alzheimer's disease or mild Alzheimer's dementia by meeting one of the following scores:

  • Clinical Dementia Rating (CDR)-Global Score of 0.5 to 1
  • Mini-Mental Status Exam (MMSE) score between 24 and 30
  • Montreal Cognitive Assessment (MoCA) score of at least 18

Recommendation 2
Before initiating aducanumab-avwa (Aduhelm®), prescribers must provide medical records for the following pre-treatment testing:

  • Genetic testing to assess apolipoprotein E ε4 carrier status, and
  • Positron emission tomography (PET) scan or cerebrospinal fluid (CSF) analysis to confirm the presence of amyloid beta deposits.

Recommendation 3
Before initiating aducanumab-avwa (Aduhelm®), prescribers must attest that the patient does not have evidence of any medical or neurological condition other than Alzheimer's disease that could be contributing to the patient's cognitive impairment.

Recommendation 4
Before initiating aducanumab-avwa (Aduhelm®), prescribers must attest that the patient does not have a history of a clotting disorder and is not taking any form of antiplatelet or anticoagulant medications other than aspirin ≤325 mg/day.

For continuation of therapy, providers must attest that the patient's score remained stable or improved, utilizing the same baseline assessment tool as outlined in Recommendation 1.

Botulinum Toxins

ST Requirements
Indication ST
Chronic sialorrhea* Glycopyrrolate
Headache prevention in patients with chronic migraine Two oral agents FDA-approved or compendia-supported for prevention of migraine
Overactive bladder Antimuscarinic agent or beta-3-adrenoceptor agonist
Neurogenic detrusor overactivity** Antimuscarinic agent
Urinary incontinence due to detrusor overactivity Antimuscarinic agent or beta-3-adrenoceptor agonist

*Excludes patients with Parkinson's disease and other neurodegenerative diseases.
**Excludes patients with multiple sclerosis (MS) or spinal cord injury.

Infliximab (Remicade®), infliximab-abda (Renflexis®), infliximab-axxq (Avsola™), and infliximab-dyyb (Inflectra®)

Trial of a disease-modifying anti-rheumatic drug (DMARD) or tumor necrosis factor inhibitor (TNFi) Food and Drug Administration (FDA)-approved for self-administration prior to initiation of infliximab.

Vedolizumab (Entyvio®)

Trial of a disease-modifying anti-rheumatic drug (DMARD) or tumor necrosis factor inhibitor (TNFi) prior to initiation of vedolizumab.

Please note: To obtain a PA, prescribers should contact the clinical call center at (877) 309-9493. The clinical call center is available 24 hours a day, seven days a week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain a PA. NYS Medicaid-enrolled prescribers can also initiate PA requests using the web-based application, PAXpress®. PAXpress®. is a web-based pharmacy PA request/response application accessible through eMedNY (providers can refer to the "PAXpress®" button on the right-hand side of the eMedNY homepage).

Questions and Additional Information:

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

Kathy Hochul
Governor
State of New York

Mary T. Bassett, M.D., M.P.H.
Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs