New York State Medicaid Update - January 2024 Volume 40 - Number 1

In this issue …

eConsults

Effective April 1, 2024, the New York State (NYS) Medicaid fee-for-service (FFS) program will reimburse for eConsults. Medicaid Managed Care (MMC) Plans must comply with this coverage, effective June 1, 2024. eConsults, also known as electronic consultations or interprofessional consultations between a treating/requesting provider and a consultative provider [physicians (including psychiatrists), physician assistants (PAs), nurse practitioners (NPs), midwives (MWs)], are intended to improve access to specialty expertise by assisting the treating/requesting provider with the care of the patient without patient contact with the consultative provider.

The purpose of an eConsult is to answer patient-specific treatment questions in which a consultative provider can reasonably answer from information in the request for consultation and the electronic health record, without an in-person visit. The consultative provider should respond to the eConsult request within three business days. The response should include recommendations, rationale and may include contingencies that warrant a re-consult or referral.  eConsults may not be appropriate for cases that involve complex decision-making and urgent medical decision-making.

eConsults cannot be used to arrange a referral for an in-person visit. They may be used for patients with or without an existing relationship with the consultative provider. For patients with an existing relationship with the consultative provider, eConsults may be used upon presentation of a new problem where management of the patient can be reasonably carried out by the practitioner seeking the consultation.

eConsults must be performed through electronic communication between the treating/requesting provider and the consultative provider. The complete record of the consult must be documented in the patient chart. Both the treating/requesting provider and the consultative provider can bill for the eConsult. To bill NYS Medicaid for eConsults, the provider must be enrolled in NYS Medicaid.

Patient Rights and Consent

The treating/requesting provider shall provide the NYS Medicaid member with information about the eConsult and obtain consent from the patient prior to each eConsult. A single instance of patient consent cannot apply to multiple eConsults across different specialties. Written consent is not required; however, the provider must document informed consent in the chart of the patient before the eConsult. Patients have the right to refuse an eConsult and see a consultative provider in-person if they wish to do so.

Documentation and Records

The following information must be documented in the medical record by the treating/requesting provider:

  • the written or verbal consent made by the patient for the eConsult;
  • the request made by the treating/requesting provider; and
  • the recommendation and rationale from the consultative provider.

Both the treating/requesting provider and the consultative provider are required to follow all state and federal privacy laws regarding the exchange of patient information.

Please note: In addition to Title 18 of the NYCRR §504.3(a), providers may be subject to other record retention requirements (e.g., contractual requirements under the MMC program).

Billing

Both the treating/requesting provider and the consultative provider can bill for an eConsult through independent claims. eConsults should be billed using the following CPT codes:

Current Procedural Terminology (CPT) Code NYS Medicaid Rate Billed By Description
99451 Consultative Provider Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient's treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time. $28.46
99452 Treating/Requesting Provider Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes. $26.56

To bill the above CPT codes, providers must meet all elements of the code, adhere to the American Medical Association (AMA) guidelines related to frequency of billing these codes, as well as follow billing restrictions when the eConsult leads to a face-to-face encounter. All NYS Medicaid billing guidelines, including those for practitioner types, apply.

Questions and Additional Information:

  • NYS Medicaid FFS billing and claims questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYS Medicaid FFS telehealth coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at telehealth.policy@health.ny.gov.
  • MMC enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the specific MMC Plan of the enrollee. MMC Plan contact and plan directory information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

|top of page|

NY State of Health Public Health Emergency Unwind Fact Sheet for Providers Now Available

NY State of Health, the New York State (NYS) official health plan marketplace (Marketplace), released a provider fact sheet titled Unwinding the Public Health Emergency, with guidance on assisting patients who may be affected by the public health emergency (PHE) unwind. The fact sheet informs providers on how they can help minimize the number of New Yorkers at risk of losing their public health insurance, including steps their patients should take to renew their coverage or explore other health insurance options, if they are no longer eligible for NYS Medicaid, Child Health Plus (CHPlus) or the Essential Plan (EP).

The fact sheet links to the NY State of Health Unwinding from the COVID-19 Public Health Emergency: A Communications Tool Kit to Keep New Yorkers Covered, which includes communications tools and templates, as well as the latest news and updates regarding how NYS is supporting New Yorkers for the duration of the PHE Unwind process. Additionally, providers can find the NY State of Health "Take Action to Keep Your Health Insurance" web page, also linked, which is maintained with important information relevant for consumers.

|top of page|

Zynteglo® (betibeglogene autotemcel): Medicaid Practitioner Administered Drugs Update

Zynteglo® (betibeglogene autotemcel) will be reimbursed by the New York State (NYS) Medicaid fee-for-service (FFS) program for Medicaid Managed Care (MMC) enrollees and FFS members. The following coverage criteria for Zynteglo® (betibeglogene autotemcel) applies to FFS members and MMC enrollees, with consideration of approval for treatment-related medical care for MMC enrollees:

  • the patient has a diagnosis of transfusion-dependent beta-thalassemia;
  • the patient is a candidate for allogenic hematopoietic cell transplantation, but ineligible due to the absence of a donor; and
  • the patient is less than or equal to (≤) fifty years of age. If the patient is less than (<) five years of age, the patient weight must be greater than or equal to (≥) six kilograms.

For FFS members, the Zynteglo® (betibeglogene autotemcel) Clinical Criteria Worksheet is located on the NYS Department of Health (DOH) "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance - Medicaid Fee-for-Service" web page. Providers should follow the provided outlined process.

For MMC enrollees, the Zynteglo® (betibeglogene autotemcel) Clinical Criteria Worksheet is located on the NYS DOH "New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance - Medicaid Managed Care" web page. The MMC Plan is responsible for submission of this worksheet to NYS DOH by secure email at NYRx@health.ny.gov.

For additional information regarding the development of the coverage criteria above, providers should refer to the NYS DOH "Drug Utilization Review (DUR) Board - 2022" web page.

Billing for Zynteglo® (betibeglogene autotemcel)

Facilities and pharmacies enrolled with NYS Medicaid will be reimbursed for the cost of Zynteglo® (betibeglogene autotemcel). Reimbursement requires submission of the following:

  • Medical Assistance Health Insurance Claim Form (eMedNY 150003), that includes both the following:
    • the unclassified biologics, Healthcare Common Procedure Coding System (HCPCS) code "J3590" is used until it is replaced with a specific HCPCS code for Zynteglo® (betibeglogene autotemcel);
    • the National Drug Code (NDC) associated with the drug; and
  • a copy of the drug invoice dated within six months prior to the date of service and/or should include the expiration date of the drug.

Pharmacy providers must have an "0442" category of service (COS) to submit the eMedNY 150003 form to NYS DOH.

Please note: If actual acquisition cost exceeds what is allowed on the eMedNY 150003 form, a maximum of $99,999.99 should be submitted on the claim form. Providers will be reimbursed up to the acquisition cost of the drug based on the invoice submitted, irrespective of the amount entered. Further information can be found in section 6.5 (Drugs Administered Other Than Oral Method) of the Physician Medicine, Drugs and Drug Administration Procedure Codes - eMedNY New York State Medicaid Provider Procedure Code Manual.

For FFS members, payment for drug administration will be made through the outpatient Ambulatory Patient Groups (APG) payment when administered in a clinic setting or, if administered on an inpatient basis, following the All Patient Refined-Diagnosis Related Groups (APR-DRG).

For MMC enrollees,payment for drug administration will be made through the MMC Plan. Providers should check with the MMC Plan regarding specific medical coverage criteria, and reimbursement. MMC Plan contact and plan directory information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

Questions and Additional Information:

|top of page|

Reminder: New York State Medicaid Covers Nirsevimab, Abrysvo and Arexvy for the Prevention of Respiratory Syncytial Virus

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC), including mainstream MMC Plans and Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), provide coverage for Nirsevimab, Abrysvo and Arexvy for the prevention of the Respiratory Syncytial Virus (RSV) when administered as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). RSV ACIP recommendations can be found on the CDC "RSV ACIP Vaccine Recommendations" web page.

Nirsevimab

Nirsevimab has been ACIP-recommended for inclusion in the Vaccines for Children (VFC) program. NYS Medicaid provides reimbursement for the administration of VFC vaccines/products provided at no cost to providers. As such, NYS Medicaid will not reimburse for the cost of Nirsevimab. FFS billing guidance can be found in the New York State Medicaid Coverage of Respiratory Syncytial Virus Monoclonal Antibody (Nirsevimab) for Infants article published in the September 2023 issue of the Medicaid Update.

Abrysvo and Arexvy

Current Procedural Technology (CPT) codes, shown in Table 1 below, have been added to the Physician, Nurse Practitioner, Midwife, Ordered Ambulatory, and Pharmacy fee schedules, as well as the 3M APG Grouper Pricer for outpatient clinic reimbursement. FFS providers should follow the appropriate billing guidance found in the Medicaid Fee-for-Service Coverage Policy and Billing Guidance for Vaccinations article published in the July 2020 issue of the Medicaid Update.

Table 1:
CPT Code Code Description
90678 (Abrysvo) Respiratory syncytial virus vaccine, prefusion F (preF), subunit, bivalent, for intramuscular use.
90679 (Arexvy) Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use.

NYRx Billing Instructions for Qualified Pharmacies for Abrysvo and Arexvy

Pharmacies must submit the vaccine using the applicable procedure codes, shown in Table 1 above, via the National Council for Prescription Drug Programs (NCPDP) D.0 format. Pharmacies will bill with a quantity and day supply of "1". Additional information for billing the appropriate administration code can be found on the NYRx, the New York State Medicaid Pharmacy Program - Pharmacists as Immunizers Fact Sheet.

Table 2:
NCPDP D.0 Claim Segment Field Procedure Description
436-E1 (Product/Service ID Qualifier) Enter the applicable value, which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code.
407-D7 (Product/Service ID) Enter the applicable procedure code for administration and/or the vaccine.
442-E7 (Quantity Dispensed) Enter the value of "1".
405-D5 (Day Supply) Enter the value of "1".

Providers should refer to the NYRx the NY Medicaid Pharmacy Program - Pharmacy Manual Policy Guidelines for further guidance on origin code and serial number values that must be submitted on the claim for "pharmacy dispensing" when applicable for non-patient specific orders. Enter a value of "5" in field 419-DJ (Prescription Origin Code) and a value of "99999999" in field 454- EK (Scheduled Prescription ID Number). Additionally, providers should refer to the NYS Department of Health (DOH) Office of Health Insurance Programs (OHIP) Standard Companion Guide - Transaction Information.

Reminder for Pharmacy and Medical Claims

The National Provider Identifier (NPI) of the ordering provider is required on the NYS Medicaid claim. Additionally, providers must not bill for the provision of the RSV vaccine to NYS Medicaid members who are also enrolled in Medicare. Dually eligible individuals will continue to access full coverage of immunization services through Medicare.

MMC Billing Instructions

For NYS Medicaid members enrolled in an MMC Plan, providers must contact the specific 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 and Additional Information:

  • Additional information related to RSV can be found on the CDC "RSV Advisory Committee on Immunization - Practices (ACIP)" web page.
  • NYRx and/or FFS billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • NYS Medicaid NYRx pharmacy coverage and policy questions should be sent by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
  • FFS medical coverage and policy questions should be directed to OHIP DPDM by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan of the enrollee.

|top of page|

Updated Fees for Family Planning Services

Supported by the 2023-2024 State Budget investment to stabilize and strengthen the New York State (NYS) reproductive healthcare system, NYS Medicaid has increased fees for certain family planning services. Effective January 1, 2024, NYS Medicaid fee-for-service (FFS) increased the reimbursement for family planning services paid in the Contraceptive Management Ambulatory Patient Group (APG) 875.

Billing NYS Medicaid FFS:

  • Freestanding Diagnostic and Treatment Centers (D&TCs), Hospital Outpatient Department Clinics (OPD) and Ambulatory Surgery Centers (ASC) FFS claims for family planning services with evaluation and management procedure codes and primary diagnosis from the Z30 are assigned to the contraceptive management APG 875.
  • All claims for family planning services must also contain a "Y" in the Family Planning box in the header of the claim. If a payment is made for a family planning procedure, based on a Z30 series diagnosis, and the claim does not include a "Y" in the Family Planning box, some or all payment for the claim may be subject to recovery under audit. The inappropriate use of a Z30 diagnosis could also result in an audit-based recovery. Providers should be sure to follow all appropriate guidelines with respect to using a diagnosis from the Z30 series.
  • The assigned weight for APG 875 has been increased from 1.2543 to 1.63059.

Medicaid Managed Care Billing Instructions

Free Access Policy

Free Access means Medicaid Managed Care (MMC) enrollees may obtain family planning and reproductive health services, human immunodeficiency virus (HIV) testing and pre-test and post-test counseling when performed as part of a family planning and reproductive health encounter from any qualified NYS Medicaid health care provider, chosen by the MMC enrollee. No referral from the primary care provider (PCP) or approval by the MMC Plan is required to access such services. However, routine obstetric and/or gynecologic care, including hysterectomies, pre-natal, delivery and post-partum care are not covered under the Free Access policy, and are the responsibility of the MMC Plan. MMC Plans are advised to review Utilization Management criteria to ensure alignment with this policy.

For NYS Medicaid members enrolled in an MMC Plan, providers should contact the specific 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 and Additional Information:

|top of page|

Medicaid Managed Long Term Care Transportation Carve Out Begins March 1, 2024

Consistent with the Medicaid Redesign Team (MRT) II recommendation, the New York State (NYS) Department of Health (DOH) will carve out non-emergency medical transportation (NEMT) from the Medicaid Managed Long Term Care (MLTC) benefit package, excluding Program of All-Inclusive Care for the Elderly (PACE). The transportation component of the capitated rates will be removed, effective March 1, 2024.

Beginning March 1, 2024, NEMT services should be accessed by contacting Medical Answering Services (MAS), the statewide contracted Transportation Broker. For additional information on NEMT through MAS, providers should refer to the MAS website. Downstate enrollees in New York City (NYC), Nassau, Suffolk, Westchester and Putnam Counties should contact MAS by telephone at (844) 666-6270. Upstate enrollees in all other counties can contact MAS by telephone at (866) 932-7740.

Within the MLTC benefit package, many Social Adult Day Care (SADC) programs handle their own transportation either with their own vehicles or, or by contracting directly with a transportation provider. These programs will continue to manage their own transportation after the carve out and should continue to bill plans as usual. Members who have historically requested trips to SADCs through their MLTC plans or through their plan’s transportation broker will have their trips managed through MAS, effective March 1, 2024.

Questions:

|top of page|

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.
Acting Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs