Guide to Edits: Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care Version 3.0

  • Guidance also available in Portable Document Format (PDF)

Guide to Edits included in the Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care Version 3.0 (PDF)

Note: New text added to version 3.0 has been underlined.

Update Made Updated Text Location
Added sub-bullets to clarify that some aspects of I.B.c.i fall under NYRx transition and are not the responsibility of the MMC plan.
  • Immunizations in accordance with NYS or NYC recommended childhood immunization schedule
    • ⮚Immunizations administered by a pharmacist are covered by NYRx, the Medicaid Pharmacy program, effective April 1, 2023.
  • Reproductive health care
    • ⮚Condoms and diaphragms are covered by NYRx, the Medicaid Pharmacy program, effective April 1, 2023.
  • Laboratory tests
    • ⮚Covid-19 testing and specimen collection is covered by NYRx, the Medicaid Pharmacy program, effective April 1, 2023, when billed by a pharmacist.
 Pg. 6
X.A.3 removed "medications", as due to NYRx transition, MMC plans are not responsible for utilization review of medications. medications. Pg. 23
X.E.1 deleted text as items are carved out due to NYRx transition. hearing aids and batteries; nebulizers; inhalers Pg. 26
X.G Updated Pharmaceuticals and DME/Supplies section to reflect the pharmacy transition to NYRx, the Medicaid Pharmacy program.
  1. 29-I Health Facilities will continue to cover the cost of prescription drugs (except those that are covered under the Foster Care Drug Carve-Out list) and durable 27 medical equipment under the Medicaid residual per diem until children/youth are transitioned into Medicaid Managed Care on July 1, 2021.
  2. Effective July 1, 2021, the Foster Care Drug Carve-Out List will no longer apply, and children/youth will access the pharmacy benefit via the MMCP, or Medicaid FFS, depending on enrollment status. See also 29-I Billing Guidance.
    1. For child/youth who are enrolled in MMC:
      1. Pharmaceuticals and equipment will no longer be billed to the VFCA
      2. Pharmaceuticals and pharmacy procedure codes and medical supplies included in the MMC Model Contract Benefit Package will be billed by the pharmacy or equipment provider to the MMCP. The Pharmacy Procedure Code Manual can be found here: https://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy_Procedure_Codes.pdf
      3. More information on the Managed Care Pharmacy benefit can be found here: https://mmcdruginformation.nysdoh.suny.edu/
    2. For members remaining in Medicaid FFS:
      1. Pharmaceuticals and equipment will no longer be billed to the VFCA
      2. The Foster Care Drug Carve Out list will no longer apply. All Pharmaceuticals and pharmacy procedure codes and medical supplies that are covered under Medicaid fee-for-service will be billed by pharmacies to Medicaid FFS
      3. More information on Medicaid FFS Pharmacy benefits, including the Medicaid FFS Formulary https://www.emedny.org/info/formfile.aspx and a link to the Preferred Drug Program can be found at: https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf
  1. As per the MMC Model Contract Section 21.25, MMCPs will contract with an adequate number of pharmacies to serve children in foster care, including contracting or otherwise seeking to arrange access to identified pharmacies that offer blister packaging and/or delivery services for enrolled children in foster care.
  2. As required in the Children's Standards, Section 3.8.0 i-v, MMCPs will ensure access to medically necessary medications wherever the child in foster care is placed, including:
    1. Access to out of network pharmacies;
    2. At least one 30-day refill within the first 90 days of a new placement in foster care, whether or not the child/youth is a new enrollee, consistent with transitional fill requirements in the MMC Model Contract;
    3. Prior authorization processing as fast as the enrollee's condition requires and consistent with timeframes in the MMC Model Contract; and
    4. Rapid replacement of lost medications as medically necessary, including allowing exceptions to refill timeframes.
  3. As required in the Children's Standards, Section 3.9 D, MMCPs must expand capacity to develop and implement a defined pharmacy management program for Behavioral Health (BH) drug classification to include the following areas for children/youth:
    1. Specialized pharmacy management policies for BH providers, PCPs, and other specialty provider types;
    2. Use of data to identify opportunities for intervention that address safety, gaps in care, utilization, and cost stratified by age group; and
    3. Protocols to monitor the use of psychotropic medications including the oversight of any child under the age of six taking any psychotropic medications; on more than one medication from the same class; or on three or more psychotropic medications.
    1. Effective April 1, 2023, Medicaid members, including children/youth placed in foster care, enrolled in an MMCP will have their pharmacy benefits transitioned to NYRx, the Medicaid Pharmacy program, formerly known as the Medicaid fee-for-service pharmacy program.
      1. For child/youth who are enrolled in an MMCP:
        1. Pharmaceuticals and equipment will no longer be billed to the MMCP
        2. Pharmaceuticals, pharmacist administered vaccines and supplies, enteral and parenteral nutrition, family planning, and medical/surgical supplies listed in the New York State Medicaid Program Pharmacy Procedure Codes document will be billed by the pharmacy or equipment provider to NYRx. The Pharmacy Procedure Code Manual can be found here: https://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy _Procedure_Codes.pdf
      2. Nothing will change for members remaining in Medicaid FFS
Pg. 27