Transition and Communication Activities Timeline

  • Document - also available in Portable Document Format (PDF)

The following charts provides additional context and information related to the New York State Department of Health's (NYS DOH) transition and communication activities for the pharmacy benefit transition from Managed Care (MC) to NYRx (Fee-For-Service (FFS)), effective April 1, 2023.

Who What When Notes
NYS DOH Formulary & Eligibility Compliance Report ✓
By 9/30/2022		 Plan specific reports detailing non-compliance of formulary coverage and eligibility.
Managed Care Plans Formulary & Eligibility Compliance Review ✓
10/1/2022		 Plans should complete review of non-compliance for formulary and eligibility to ensure actions are taken to address (mitigate) non-compliance, per the last data file provided by NYS DOH. Plans should continue to review their coverage of formulary and eligibility compliance on a regular basis.
Managed Care Plans Last Submission of Prescriber Prevails Prior Authorization Activity to NYS DOH ✓
10/20/2022		 Includes Prior Authorizations through 9/30/2022.
Managed Care Plans Submit test files of approved Prior Authorizations (PA). ✓
11/22/2022		 Submit test files to NYS DOH in accordance with testing guidance shared with the Medicaid Managed Care Plans.
NYS DOH Final review of plan submitted formulary files & feedback ✓
11/24/2022		 Review of MCP submitted formulary information and feedback.
Managed Care Plans Formulary file freeze ✓
12/31/2022		 No changes to be made for o n formulary/off-formulary status. Other maintenance such as adding new drugs, criteria changes due to FDA labeling changes would continue.
NYS DOH Formulary file freeze ✓
12/31/2022		 No changes to be made for preferred/non-preferred status. Other maintenance such as adding new drugs, criteria changes due to FDA labeling changes would continue.
Managed Care Plans Formulary file submission to NYS DOH ✓
1/6/2023		 Includes changes/updates as of as of 12/31/2022, in order to update the Medicaid Managed Care Pharmacy Benefit Information Center.
NYS DOH Deliver daily claims test files to plans ✓
  1. 10/13/2022
  2. 10/28/2022
  3. 11/10/2022
  4. 12/8/2022
  5. 1/17/2023
  6. 1/18/2023
  7. 1/24/2023
 Deliver test files to Medicaid Managed Care Plans in accordance with the Interface Control Document specifications (ICD) and technical needs. Proposed schedule:
  1. Form & Fit File #1
  2. Form & Fit File #2
  3. Test File #1
  4. Test File #1 (resent)
  5. Test File #2
  6. Test File #3
  7. MCP Readiness Confirmation via Daily Claims Confirmation Form
Managed Care Plans Submit Approved Prior Authorizations (PAs) to NYS DOH
✓1/25/2023
✓3/8/2023
4/7/2023
 PAs will be honored after the transition.
  1. Initial file submission
  2. 1st "Catch-Up" File Submission - New Additions 2nd "Catch-Up" File Submission - New Additions
NYS DOH Load Approved Clinical Medicaid Managed Care Prior Authorizations (PAs)
✓2/8/2023
✓3/15/2023
4/14/2023
 Prior Authorizations approved by Medicaid Managed Care plans will be honored after the transition.
  1. Initial File Submission
  2. 1st "Catch-Up" File Submission 2nd "Catch-Up" File Submission
Managed Care Plans Confirm system readiness for claim denials ✓
3/1/2023		 Ensure Managed Care Plan systems are updated to deny pharmacy claims effective 4/1/2023 with standard NYS DOH approved messaging
  • NCPDP Reject Code 831: Product Service ID Carve-Out, Bill Medicaid Fee For Service
  • Additional Message Field 526-FQ: Bill NYRx, Medicaid Pharmacy Program, EFFECTIVE 04/01/2023. SUBMIT CLAIM TO BIN: 004740
Managed Care Plans Pharmacy (NCPDP) Claim Encounter Submissions Ongoing, for service dates through 3/31/2023. Ensure that encounters are submitted daily, not more than 1 business day from the date of adjudication of the corresponding claim. In conformance with Plan's PBM agreement.
NYS DOH Outpatient Pharmacy Per Member Per Month (PMPM) Payments to plans End 3/31/2023, except for retroactive adjustments Plans may initiate retroactive adjustments when:
  • there was active enrollment prior to 4/1/23 that had not been previously billed for, or
  • a plan billed for a member prior to 4/1/23, for which there was not active enrollment. In this case, the plan would reverse the capitation claim in a subsequent period.
Managed Care Plans Member Material Changes By 4/1/2023 Make necessary changes to member materials and ID Cards.
NYS DOH Outpatient pharmacy inquiries received by the Plans Beginning 4/1/2023 NYS DOH has provided the process to the Managed Care Plans of how to refer pharmacy benefit inquires to NYRx.
NYS DOH Collaborative DUR Continuing After 4/1/2023 Provide DUR information and other related reports that will assist plans with medication adherence and/or disease management programs.
NYS DOH Transition Period 4/1/2023 - 6/30/2023 The Department has established a transition period of a minimum of 90 days from April 1, 2023, through June 30, 2023. This is to ensure that members can obtain medications through FFS, that had been previously covered by their Medicaid Managed Care Plan without going through prior authorization. During the transition period, members will be provided with a one-time, temporary fill for drugs that require prior authorization under the FFS program (e.g., non-preferred products).
NYS DOH Daily Claims File Beginning 4/2/2023 NYSDOH begins delivering daily claims files (including paid, denied and reversed) to the Managed Care Plans.
NYS DOH Supplemental Data Reports 4/17/2023 NYSDOH begins delivering agreed supplemental data reports to the Managed Care Plans for Medication Adherence and First Fill.
Managed Care Plans Pharmacy Benefit Manager Quarterly Report Quarter 2, 2023 Submit quarterly Pharmacy Benefit Manager report for Quarter 1 2023. Note: This will be the last quarterly PBM report submitted by MCPs.
Managed Care Plans Provider Network Data Set (PNDS) File Submission - Quarter 1 TBD Submit Quarter 1 PNDS data to NYS DOH including pharmacy network data. Note: Future PNDS data submissions (Quarter 2 and thereafter) to NYS DOH should exclude pharmacy network data.
Managed Care Plans Claims submission deadline Per Plan's agreement with their PBM The last day that Managed Care Plans will pay claims for service dates prior to 4/1/2023.
Managed Care Plans Physician Administered Claim Encounter Submissions N/A Physician administered drugs, when billed as an institutional or medical claim, will continue to be provided by the Managed Care Plans and claim encounters will continue to be submitted to NYS DOH.
Managed Care Plans DUR Reports N/A DUR survey for 2023 - Due to CMS by 6/30/2023 . The reporting period is 10/1/2021 - 9/30/2022. DUR survey for 2024 - the reporting period is 10/1/2022 - 9/30/2023 (Only member data through 3/31/2023). Physician administered drug information will continue to be required post transition.
Who What When Notes
NYS DOH Website Updates: 6/30/2022 -6/30/2023 Make relevant website updates such as:
  • Notification of transition (e.g., a banner)
  • How to find the Medicaid Client Identification Number (CIN) on the Managed Care Plan ID card.
  • Links to relevant Medicaid Update articles
NYS DOH Medicaid Update and Email Blast ✓
11/7/2022		 Initial Medicaid Update Article published.

Part 1 - October 2022 (PDF) (Web)
NYRx programs that will apply to Medicaid Managed Care members starting April
NYS DOH Plan Notice of Benefit Change ✓
11/9/2022		 Pursuant to Section 4.3 of the Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Model Contract, Modification of the Benefit Package Services, the Department of Health (Department) must provide Plans at least 60 days advance notice of modifications to the benefit package.
Managed Care Plans Member Notice of Change ✓
1/30/2023-2/24/2023		 Mail Member Notice of Change per assigned mailing schedule provided by NYS DOH. The Member Notice of Change informs members of the change and that they can use their plan ID Card or their Medicaid Card to access pharmacy services
Managed Care Plans Website Updates ✓
2/1/2023 - 3/31/2023		 Make relevant website updates.
NYS DOH Medicaid Update ✓
2/9/2023		 Second Medicaid Update Article published.

Part 2 - January 2023 (PDF) (Web)
Message responses to claims submissions, including transition fills
Managed Care Plans Member Notice of Change for Dual Eligible ✓
2/27/2023-3/3/2023		 Mail Member Notice of Change for Dual Eligible members per assigned mailing schedule provided by NYS DOH. The Dual Eligible Member Notice of Change informs members of the change and that they can use their plan ID Card or their Medicaid Card to access pharmacy services
Managed Care Plans Targeted Member Notice of Recipient Restriction ✓
2/27/2023-3/10/2023		 Notify members with restrictions imposed by the Office of the Medicaid Inspector General (OMIG) about the carryover of restriction lift/end dates to NYS Medicaid FFS.
Managed Care Plans Non-FFS-Enrolled Provider Communication ✓
2/27/2023-3/17/2023		 Managed Care Plans will send targeted communications regarding the need to enroll in Fee-For-Service (FFS) effective 4/1/2023 to non-enrolled in-network and out-of-network providers (pharmacies, prescribers, and Durable Medical Equipment (DME)).
NYS DOH Custom provider notifications ✓
3/7/2023-3/21/2023		 Notify prescribers who have patients with prescriptions for non-preferred products about the transition fill period April 1 - June 30, 2023 Notify pharmacy providers about the Brand Less Than Generic (BLTG) Program and the point of service message when submitting claims for the generic version of a drug in BLTG.
NYS DOH Targeted Member Notice: Transition Fill ✓
3/7/2023-3/21/2023		 Notify members with prescriptions for non-preferred products about the transition fill period April 1 - June 30, 2023.
NYS DOH Medicaid Update ✓
3/16/2023		 Third Medicaid Update Article published.

Part 3 - March 2023 (PDF) (Web)
  • Dual eligible coverage
  • Medicare Limited Income Newly Eligible Transition Program (LINET)
  • Information for DME providers
  • PA guidance for DME
NYS DOH Update applicable system generated member notices. Effective 4/1/2023 Conduct appropriate updates to the system generated notices that provide a description of the pharmacy benefit.
  1. NYSOH Member Eligibility Notices for members who enroll in Medicaid via the NYSOH.
  2. Client Notice Subsystem Medicaid Acceptance Notices for members who enroll in Medicaid via their Local Department of Social Services (LDSS) For more information on where a member should enroll (NYSOH or LDSS) please review the FAQ "How do I apply for Medicaid?" within the General Medicaid FAQs section of the Medicaid in New York State website.
Managed Care Plans Claims Denial Messaging Effective 4/1/2023 Implement claim denial messaging that notifies pharmacies to submit claims to the FFS program.