FIDA Open Questions FAQ

December 2016

  • FAQs also available in Portable Document Format (PDF)

1. May FIDA Plans make remote access (telephone, video call, or other conference call technology) available to Participants so that they may participate in a PAC meeting if they choose not to travel to the location of the meeting?

A. Yes. FIDA Plans may make this option available for Participants to select. The TWC will be revised to reflect this. FIDA Plans must continue to allow for and accommodate in–person participation for all PAC meetings.

2. May FIDA Plans invite MLTC members to FIDA PAC meetings?

A. Plans may invite MLTC members to attend FIDA PAC meetings. These MLTC Participants will not count towards Core 5.3 reporting requirements.

3. If a FIDA Plan invites MLTC members to FIDA PAC meetings, are these PAC meetings to be counted as marketing/sales events or appointments?

A. No. CMS and DOH do not consider PAC meetings by definition to be marketing/sales events and appointments since they are not designed to steer or attempt to steer potential enrollees toward a plan or limited set of plans (per section 70.9 of the Medicare Marketing Guidelines). However, the plans should be mindful of the definition of marketing, and should the purpose of these PAC meetings shift to steering enrollees toward enrollment in a plan (or should the purpose of materials used do the same), those would become marketing events (and marketing materials) subject to the MMG.

4. May a FIDA Non-Participating Provider appeal FIDA Plan decisions through the FIDA integrated appeals process?

A. Non–Participating Providers have always been able to appeal a FIDA Plan decision through the FIDA integrated appeals process when doing so on behalf of a Participant. Non-Participating Providers have not been allowed to appeal on their own behalf using the FIDA integrated appeals process. CMS and NYSDOH are changing this policy. Guidance has been issued to specify the details of the policy and how plans must implement it. This policy change took effect November 29, 2016, when this guidance was released.

5. Does SSL Section 364j, PHL – Section 273 apply to FIDA?

A. SSL – Section 364j, PHL – Section 273 took effect on 6/22/16. This law requires all Medicaid plans to cover without prior authorization preferred formulations of buprenorphine or injectable naltrexone. Because these items are required to be covered through Part D coverage, this new state law does not require FIDA Plans to lift prior authorization requirements (which are optional under Part D). At this time, however, NYSDOH is asking and strongly encouraging plans to voluntarily comply. Accordingly, we are urging FIDA Plans to lift this prior authorization requirement through an amendment to their Part D formulary. This may be accomplished at the next regularly scheduled opportunity for Part D formulary updates. We encourage FIDA Plan to voluntarily change their Part D formulary to remove prior authorization requirements out of concern about the growing Opioid overdose epidemic.

6. NY Medicaid rules changed for Insect Repellent on 9/1/16. Do these changes apply to FIDA Plans?

A. On 9/1/16, NYSDOH released an eBlast announcing that, effective immediately, insect repellent is a required covered service for all Medicaid plans. Insect repellent must be prescribed and covered for any Medicaid recipient who is travelling to or return from a Centers for Disease Control recognized area of localized Zika transmission as reported here. Several FIDA Plans recently opted to offer insect repellent as a covered service. This new requirements applies to those plans and all others. PBP revisions for 2016 and 2017 will be required and guidance around that will be forthcoming.