New York State Medicaid Update - October 2023 Volume 39 - Number 15
In this issue …
- All Providers
- Attention Ambulance Providers: Emergency Triage, Treat, and Transport
- Payment Error Rate Measurement Upcoming Request for Medicaid Provider Documentation
- New York City Health Coverage Symposia Training
- NY State of Health Annual Open Enrollment Period Launched November 16, 2023 for 2024 Health Insurance
- Pharmacy
- Policy and Billing
Ambulance Providers: Emergency Triage, Treat, and Transport
On November 24, 2021, New York State (NYS) Medicaid launched its Emergency Triage, Treat, and Transport (ET3) program, which mirrors the Center for Medicare and Medicaid Services (CMS) ET3 Model, allowing qualified participating ambulance providers to treat patients in place, or transport to destinations other than the emergency department, as appropriate.
CMS recently announced, "The ET3 Model will end early on December 31, 2023, two years prior to the performance period end date. This decision was made due to lower-than-expected participation and lower than projected interventions. Emergency Medical Services remain an area of focus for CMS, and we believe that the lessons learned from the ET3 Model can aid in the development of potential future initiatives. This decision does not affect Model Participants' participation in the Model through December 31, 2023." For additional information regarding CMS' announcement, providers should refer to the CMS "Emergency Triage, Treat, and Transport (ET3) Model" web page.
In accordance with Title 18 of the New York Codes, Rules and Regulations (NYCRR) §505.10, "Medicaid payments under the ET3 model will continue only for the duration of the Medicare demonstration approved by Capability Maturity Model Integration (CMMI) and will be terminated when either the demonstration period expires or upon termination of Medicare participation by CMMI at any time for any reason." Therefore, the NYS Medicaid ET3 program will end on December 31, 2023.
The NYS Department of Health (DOH) Bureau of Emergency Medical Services and Trauma Systems Statewide Basic Life Support Adult and Pediatric Treatment Protocols document, instructs EMS providers to, "transport (patients) to the closest appropriate receiving facility in accordance with regional facility destination policies for travel time, facility capabilities, and NY State designation." Therefore, when practicing in compliance with these protocols, NYS Medicaid will continue to pay for emergency ambulance transportation to urgent care centers, federally qualified healthcare centers (FQHCs), mental health or substance use disorder treatment centers, and physician offices. This policy applies to all enrolled ambulance providers and is not limited only to those that had previously obtained CMS ET3 approval. For dates of service after December 31, 2023, NYS Medicaid payments can no longer be made to any ambulance provider for treatment in place.
Questions
Questions regarding this matter should be directed to the NYS DOH Medical Transportation Unit by telephone at (518) 473-2160 or by email at MedTrans@health.ny.gov.
Payment Error Rate Measurement Upcoming Request for Medicaid Provider Documentation
The Centers for Medicare and Medicaid Services (CMS) will be measuring improper payments in the Medicaid and State Child Health Insurance programs under the Payment Error Rate Measurement (PERM) program. New York State (NYS) will be participating in the PERM program for the sixth time (federal fiscal year 2021 being the last time NYS participated in the PERM program). CMS, along with their contractor and NYS Office of the Medicaid Inspector General (OMIG), have the authority to collect information under sections 1902(a)(27) and 2107(b)(1) of the Social Security Act. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) statutes and regulations require the provision of such information upon request, and the information can be provided without patient consent.
Empower Al (formerly NCI Inc.) is returning as the CMS review contractor, and in partnership with NYS OMIG, will be requesting documentation from providers for randomly selected claims to perform a medical review. Results of the last cycle showed the state error rate was 1.63 percent, compared to a national average of 13.9 percent*. NYS OMIG was also able to successfully overturn over three quarters of claims that were originally determined to be in error utilizing records submitted by providers in response to documentation requests. Therefore, as with prior PERM reviews, although NYS OMIG will pursue appropriate action for payments determined to be in error, providers generally benefit from cooperating with requests for documentation.
*For additional information regarding the national average error rate for medical reviews, providers can refer to the Department of Health and Human Services - Agency Financial Report - Fiscal Year 2021
If the submitted claim of a provider is selected for review, the CMS contractor and NYS OMIG will request written documentation to substantiate claims paid. Providers are asked to submit copies of the specific medical documents for the patient. This will be requested in the letter received from the CMS contractor, with instructions to submit the records directly to the CMS contractor with a second copy to NYS OMIG. For providers who submit records, please ensure that the records are sent in a secure manner. Email and faxes are preferred, as they aid in efficiency. Records may also be mailed to the following address:
Attention: PERMOffice of the Medicaid Inspector General
800 North Pearl Street First Floor
Albany, NY 12204
Requests for documentation are anticipated to begin in late Fall 2023. The audit period of sampled claims are those paid between July 1, 2022, and June 30, 2023. Requests and subsequent receipt or non-receipt of documentation will be tracked. Compliance with medical record requests and providing full medical records for the randomly selected claims is required. Failure to provide requested records will result in a determination by CMS of erroneous payment and NYS OMIG will pursue recovery.
Questions
Questions should be directed to the PERM Project Staff by telephone at (518) 408-0844 or by email at PERMNY@omig.ny.gov.
New York City Health Coverage Symposia Training
Join New York City (NYC) Health + Hospitals Office of External and Regulatory Affairs as well as NYC Health + Hospitals/Elmhurst for their annual NYC Health Coverage Symposia training, which will be held on Thursday, November 16, 2023, from noon to 4 p.m., at 79-01 Broadway, Elmhurst, NY 11373. Throughout the training, providers will receive important updates on Medicare open enrollment and 2024 changes, New York State (NYS) Medicaid renewals, NY State of Health open enrollment, the Inflation Reduction Act, the No Surprises Act, NYC Care, NYS Elderly Pharmaceutical Insurance Coverage (EPIC) program, and more. Providers are encouraged to register for the training on Thursday, November 16 via the Eventbrite "Health Insurance Symposium - Queens" web page.
Additional training dates are available for those who are unable to attend the initial training on Thursday, November 16:
- Thursday, November 30, 2023, from 9 a.m. to 1 p.m.
Hosted by NYC Health + Hospitals/Bellevue
462 First Avenue, Manhattan, NY 10016
Saul Farber Auditorium
Providers are encouraged to register for the training via the Eventbrite "Health Insurance Symposium - Manhattan" web page. - Thursday, December 7, 2023, from 11:30 a.m. to 3:30 p.m.
Hosted by NYC Health + Hospitals/Lincoln and Frank M. Winter, CMS NYS Training Lead
234 East 149th Street, Bronx, NY 10451
1st Floor Auditorium
Providers are encouraged to register for the training via the Eventbrite "Health Insurance Symposium - Bronx" web page.
Providers are encouraged to share all NYC Health Coverage Symposia training dates with their partners and colleagues.
NY State of Health Annual Open Enrollment Period Launched November 16, 2023 for 2024 Health Insurance
The annual Open Enrollment Period (OEP) for NY State of Health, the New York State (NYS) official health plan marketplace (Marketplace), launched on November 16, 2023, for health insurance in 2024. New Yorkers shopping for health insurance coverage through the Marketplace are offered a wide selection of high-quality, comprehensive Qualified Health Plans (QHPs), with the support of certified enrollment assistors to guide the enrollment process, determine eligibility, and access any potential financial assistance. Additionally, enhanced tax credits for coverage continue through 2025. New Yorkers have until December 15, 2023, to renew or enroll in a health plan for coverage starting January 1, 2024.
New Yorkers who are unable to enroll by December 15 will still be able to enroll in health insurance, with effective dates slightly later in the year, as shown in the following table:
| Open Enrollment Period | QHP Coverage Start Date |
|---|---|
| November 16, 2023 to December 15, 2023 | January 1, 2024 |
| December 16, 2023 to January 15, 2024 | February 1, 2024 |
| January 16, 2024 to February 15, 2024 | March 1, 2024 |
Consumers can enroll in a health plan by:
- calling the NY State of Health Customer Service Center at (855) 355-5777.
- visiting the NY State of Health website. A web chat feature is available to consumers during Customer Service Center hours to help them complete their applications.
- speaking with a Certified Enrollment Assistor to receive free personalized help. Consumers can find a Certified Enrollment Assistor located on the NY State of Health "Find an Assistor or Broker" web page.
Additionally, the Marketplace will remain open for the duration of NYS renewals for all public health programs, which continues through May 2024. New Yorkers can maintain their coverage by enrolling in a QHP or the Essential Plan (EP) if they become ineligible for NYS Medicaid.
NYS continues to monitor enrollment during the renewal process with a New York State Public Health Emergency Unwind Dashboard, which tracks renewal status, demographics, and NYS program transitions every month.
Hormone Replacement Therapy for Treatment of Gender Dysphoria
This article clarifies NYRx, the New York State (NYS) Medicaid Pharmacy program, policy regarding coverage of hormone therapy for the treatment of gender dysphoria. Previous guidance regarding gender dysphoria can be found in the following Medicaid Update issues:
- Transgender Related Care and Services Pharmacy Coverage Update article published in the July 2020 Medicaid Update;
- New York State Medicaid Policy on Verification of Patient Safety to Undergo Surgery, Requests for Surgical Revisions, and Mental Health Counseling Requirements for Surgery for the Treatment of Gender Dysphoria article published in the December 2019 issue of the Medicaid Update;
- Gender Reassignment Surgery Update article published in the April 2017 issue of the Medicaid Update;
- Transgender Related Care and Services Update article published in the January 2017 issue of the Medicaid Update;
- Transgender Related Care and Services Update article published in the May 2016 issue of the Medicaid Update; and
- New York State Medicaid Updates Regulations article published in the June 2015 issue of the Medicaid Update.
NYRx covers medically necessary hormones that are Federal Drug Administration (FDA)-approved or compendia-supported for the treatment of gender dysphoria consistent with the guidance provided in the January 2017 and July 2020 Medicaid Update issues mentioned above. The official compendia sources would include American Hospital Formulary Service (AHFS) and Micromedex DrugDex. NYRx maintains a current list of drugs that meet these criteria under the section "Cross-Sex Hormones" in the NYRx, the Medicaid Pharmacy Program Preferred Drug List.
Questions and Additional Information:
- Questions regarding NYRx policy should be directed to the Medicaid Pharmacy Policy department by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
- Questions regarding Medicaid Managed Care (MMC) medical services should be directed to the MMC Plan of the enrollee. A directory by plan can be found on the New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center homepage.
Expanded Spinal Muscular Atrophy Carrier Screening 2023
Spinal Muscular Atrophy (SMA) is a genetic disorder that affects the nerves of the spine with the potential to cause severe disability and death. The American College of Obstetricians and Gynecologists (ACOG) currently recommends SMA carrier screening be offered to all individuals who are considering pregnancy or are currently pregnant. Additional information can be found on the ACOG "Carrier Screening for Genetic Conditions" web page.
New York State (NYS) Medicaid has provided coverage for SMA carrier screening since 2014. This article supersedes the Expanded Coverage for Spinal Muscular Atrophy - Prenatal Carrier Testing article published in the September 2014 issue of the Medicaid Update.
Effective October 1, 2023, for NYS Medicaid fee-for-service (FFS), and for NYS Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs) and Health and Recovery Plans (HARPs)], NYS Medicaid will expand coverage criteria to all NYS Medicaid members who are planning to become pregnant and who are currently pregnant. NYS Medicaid SMA carrier screening will be covered once per member per lifetime.
FFS Billing Guidance
The following Current Procedural Terminology (CPT) Genetic Analysis Procedure code should be billed. Please note: This is an update from the CPT code identified in the Expanded Coverage for Spinal Muscular Atrophy - Prenatal Carrier Testing article published in the September 2014 issue of the Medicaid Update. Additionally, this billing guidance supersedes the previous billing guidance published in the September 2014 issue of the Medicaid Update.
| CPT Code | Code Description | Benefit Limitations | Price |
|---|---|---|---|
| 81329 | SMN1 (survival of motor neuron 1, telomeric) (e.g., spinal muscular atrophy) gene analysis; dosage/deletion analysis (e.g., carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed. | Once per lifetime | $83.83 |
Claims will no longer pend for required documentation as the screening is now covered for all NYS Medicaid members who are considering pregnancy or are currently pregnant.
MMC Billing Instructions
For NYS Medicaid members enrolled in MMC, providers must contact the MMC Plan of the enrollee for billing instructions. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
Questions
Questions should be directed to MaternalAndChild.HealthPolicy@health.ny.gov.
The Medicaid Update is a monthly publication of the New York State Department of Health.
Kathy Hochul
Governor
State of New York
James McDonald, M.D., M.P.H.
Commissioner
New York State Department of Health
Amir Bassiri
Medicaid Director
Office of Health Insurance Programs
