Attention: New York State Medicaid Fee
The New York State Medicaid program has issued policies and billing guidance for certain drugs/drug classes for physicians, nurse practitioners , and midwives. These drugs are eligible for reimbursement when the clinical criteria outlined on the NYS Department of Health “New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance” web page, and listed web page Medicaid Update articles, are met. Drug claims must include documentation of clinical criteria as well as the following:
- manufacturer invoice showing the acquisition cost of the biologic, including all discounts, rebates, or incentives
- the invoice must be dated within six months prior to the date of service and/or should include the expiration date of the drug
- documentation of the medication administration and
- documentation of the criteria listed under the “NYS Medicaid Coverage Policy” sections of the drug-specific policies (issued in the Medicaid Update articles on the NYS DOH “New York State Medicaid Fee-for-Service Practitioner Administered Drug Policies and Billing Guidance” web page.
Attention Pharmacy Providers: Full Participation In Medicare Required For Medicaid Enrollment
This is a reminder that the New York State Medicaid program requires all NYS Medicaid-enrolled pharmacy providers to be fully enrolled in Medicare. Pharmacy providers not fully participating with Medicare will be terminated from the NYS Medicaid program on thirty days’ notice and will no longer receive reimbursement. Fully participating Medicare enrollment must include assignment of benefit , drug , and common supply billing.
Pharmacy providers can refer to the CMS National Provider Enrollment Conference document, for PECOS guidance.
New York State Department Of Health Telehealth Consumer Survey
In order to better understand patient perspectives on telehealth, the New York State Department of Health Office of Health Insurance Programs has partnered with the Office of Addiction Services and Support , Office of Mental Health , Office of Children and Family Services , and the Office for People with Developmental Disabilities to conduct the Telehealth Consumer Survey. All NYS residents, whether they have used telehealth services or not, are encouraged to complete the survey. Survey results will be used to inform future telehealth policy development within NYS.
To access the survey, visit the NYS DOH “Telehealth Consumer Survey” web page, or scan the QR code provided below using your mobile device to take the survey in your preferred language.
The survey is available in Arabic, Bengali, Chinese, English, Haitian-Creole, Italian, Korean, Polish, Russian, Spanish and Yiddish, and takes approximately five minutes to complete. Providers are encouraged to share the survey with their patients, consumers, and networks.
American Disabilities Act Notice
In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 , UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.
Early And Periodic Screening Diagnostic And Treatment Program Childhood Vaccine Counseling Coverage Benefit
Effective April 1, 2022, for New York State Medicaid fee-for-service , and effective June 1, 2022, for Medicaid Managed Care Plans , will reimburse providers for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment program when provided to Medicaid members ages 18 years of age or younger. Vaccine counseling visits align with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices .
Please note: Vaccine counseling visits for Coronavirus Disease 2019 vaccinations are reimbursed separately. Providers can refer to the , for more information. Providers may bill for childhood vaccine counseling provided to Medicaid members 18 years of age and younger:
- as a stand-alone service when all the criteria specified in this guidance are met and documented.
- in addition to an Evaluation and Management or Well-Child Visit when all the criteria of the vaccine counseling visit specified in this guidance are met and documented.
- in addition to all necessary components of the E& M/Well-Child visit.
- whether or not a recommended vaccine is administered, or vaccine administration is billed for, during the encounter.
- for up to six counseling visits per member per year for members ages zero through 18 years of age, when the member has not received the ACIP-recommended doses and does not have an appointment to receive the recommended dose.
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How To Apply For Medicaid In In New York
Due to the fact that you must stick to specific instructions with regards to submitting your paperwork, the application guidelines are different in New York than those in other states. The qualifying criteria are actually spread into two separate groups. These are MAGI and non-MAGI groups. You have to file differently depending on which group you fall into.
When it comes to MAGI application guidelines, this group includes foster children, children under 19, beneficiaries of the FPBP , relatives of caregivers or parents, women undergoing fertility treatments and pregnant women. If you fall into this group, you will have to apply for the Medicaid program via the New York State Department of Health Marketplace.
To be eligible under the non-MAGI eligibility group, you must be a recipient of one of the following:
- Medicaid Cancer Treatment Program
- ADC-related medical needy, or the
- Medicare Savings Program
If you belong to this group, you should apply for Medicaid at your local Department of Social Services.
What Do I Need To Apply
The necessary documentation needed to apply for Medicaid also depends on your category, specifically whether you fall under the Modified Adjusted Gross Income or non-MAGI guidelines. These guidelines are defined in the section below.
MAGI eligibility groups include:
- Pregnant women
- Infants and children under 19 years of age
- Childless adults who are not pregnant, 19-64 years of age, not on Medicare, and could be certified disabled but not on Medicare
- Parents/caretaker relatives
- Family Planning Benefit Program and/or
- Children in foster care
Non – MAGI Eligibility Groups include:
- Individuals 65 years of age or older, who are not a parent or caretaker relative,
- individuals who are blind or disabled who do not meet the criteria of any of the MAGI eligibility groups
- Residents of Adult Home run by LDSS, OMH Residential Care Centers/Community Residences
- Individuals eligible for the following programs:
- AIDS Health Insurance Program
- Medicaid Buy-in Program for Working People with Disabilities
- Medicaid Cancer Treatment Program
Application for Non-MAGI
The following paper application may only be printed and completed if you are applying at an LDSS for Medicaid because you are over 65 years of age or an individual in your household is deemed certified blind or disabled, or you are applying for Medicaid with a spenddown.
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How To Apply For Ny Medicaid
You may apply for Medicaid in the following ways:
- Enrollment Assistors offer free personalized help.
- To speak with the Marketplace Customer Service Center call 355-5777
- Through a Managed Care Organization
- Call the Medicaid Helpline 541-2831
- Through your Local Department of Social Services Office
Where you apply for Medicaid will depend on your category of eligibility, which might be single, childless couples, pregnant women, parent and caretaker relatives with dependent children, elderly, and/or disabled. Certain applicants may apply through NY State of Health while others may need to apply through their Local Department of Social Service . For more information on determining where you should apply read on
The Marketplace determines eligibility using Modified Adjusted Gross Income Rules. In general, income is counted with the same rules as the Internal Revenue Service with minor variations. Applications may be completed online, with an Enrollment Assistor, by mail, or by phone.
The following individuals should apply through the Marketplace :
- Adults 19-64 years of age and not eligible for Medicare,
- Pregnant Women and Infants,
- Children 1 – 18 years of age, and
- Parents and Caretaker Relatives.
The following individuals should apply with their Local Department of Social Services :
Clinics Hospital Outpatient Departments Physicians Nurse Practitioners And Midwives
A provider submitting professional claims should bill Current Procedure Terminology code “99401” for preventative medicine counseling and/or risk factor reduction intervention provided to an individual for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required.
*The D.0 Companion Guide can be found on the “eMedNY 501/D.0 Transaction Instructions” web page.
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To Order A Replacement Nys Medicaid Card:
If the cardholder receives Medicaid through your local department of social services, you can order a replacement NYS Medicaid card by calling 1-888-328-6399. Please be prepared to provide security information, including the cardholderâs date of birth and social security number.
If the cardholder receives Medicaid through the New York State of Health: Health Plan Marketplace, you can re-order a replacement NYS Medicaid card by calling 1-855-355-5777.Please be prepared to provide security information, including the account holderâs name, social security number, account number or health care exchange identification number.
Please note that P-EBT food benefits will remain available and accessible on your NYS Medicaid card for at least 274 days from the date they were issued. Once you have set up a PIN to access your P-EBT food benefits, you can check your familyâs P-EBT food benefits balance by visiting www.connectebt.com or by calling 1-888-328-6399.
For more information about P-EBT food benefits visit our Frequently Asked Questions page.
This page contains links to PDF documents. to view these documents.
New York State Medicaid Launches Emergency Triage Treat And Transport Program
On November 24, 2021, New York State Medicaid launched its Emergency Triage, Treat, and Transport program which mirrors the timing and tenets of the Centers for Medicare and Medicaid Services “ET3 Model”, allowing qualified participating ambulance providers to treat patients in place or transport to destinations other than the emergency department , as appropriate. Treatment in place must be provided by a licensed healthcare practitioner , either in person or via telehealth. Non-hospital alternative destinations include Community Mental Health Centers , substance use disorder treatment centers, Federally Qualified Health Centers , physician´s offices, and urgent care facilities. For more information about the ET3 Model in NYS Medicaid, providers can refer to the article titled The CMS Emergency Triage, Treat, and Transport Model with the Department of Health Parallel Model, published in the November 2021 issue of the Medicaid Update.
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No Existing Medicaid Coverage
If you dont already have Medicaid coverage, and you meet the above conditions, you may ask to have your Medicaid application processed more quickly by sending in a completed Access New York Health Insurance Application and the Access New York Supplement. If needed, you will also need to provide a physicians order for services and a signed
Attestation of Immediate Need.
New York State Medicaid Professional Pathology Policy
Effective April 1, 2022, New York State Medicaid fee-for-service will reimburse participating laboratories and facilities for a consultation on pathology specimens as outlined in this policy. The policy will be effective on June 1, 2022, for Medicaid Managed Care Plans, including Mainstream MMC Plans, Human Immunodeficiency Virus Special Needs Plans , and Health and Recovery Plans . Reimbursement is available for consultations after the initial specimen reading when the following criteria are met:
- the facility was not the laboratory that initially processed the specimen, and the consulting pathologist is not employed by or affiliated with the original facility and
- a pathologist with a specific specialty is necessary for comprehensive evaluation and there is not a pathologist with that specialty available at the initial laboratory and
- a consultation will aid in the diagnosis and/or treatment of a Medicaid member or
- the member is seeking treatment at the consulting facility.
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Pharmacy And Medical Billing Guidance For Spravato
Effective May 12, 2022, for New York State Medicaid fee-for service and Medicaid Managed Care Plans , the following billing guidance will be implemented for SPRAVATO® in the Medicaid program.
Drug Procured by Medical Provider :
- Drug billed by the provider using the appropriate Healthcare Common Procedure Code System code for esketamine.
- Medical observation and monitoring are billed using the appropriate Current Procedural Terminology code for Evaluation and Management . See Claim Billing Requirements table provided below.
- Providers must bill the actual acquisition cost of esketamine, inclusive of all rebates and discounts, per invoice.
Drug Dispensed by REMS-Certified Specialty Pharmacy:
- Drug billed by the pharmacy and delivered, on behalf of the patient, to the provider.
- Medical observation and monitoring are billed by the provider using the appropriate CPT code for E/M. See Claim Billing Requirements table provided below.
- A pharmacy must adhere to the program policy requirements which can be found in the Dispensing of Drugs that Require Administration by a Practitioner article, published in the August 2019 issue of the Medicaid Update.
Update On Pharmacy Billing For Compound Prescriptions
Effective April 21, 2022, New York State Medicaid will implement system enhancements regarding compound billing. Medicaid compound policy can be found in the article titled Pharmacy Billing Changes for NCPDP D.0, published in the February 2011 issue of the Medicaid Update, as well as the article titled Compound Policy: A Reminder and Clarification, published in the December 2020 issue of the Medicaid Update.
Per Medicaid policy, when billing a compound via National Council for Prescription Drug Programs D.0 transaction, providers must submit a minimum of two ingredients, or National Drug Codes , in the Compound Segment, field 489-TE . Providers can submit up to 25 NDCs using this field. Providers must also submit a compound code of “02Compound” in field 406-D6 in the Claim Segment. Claims with NDCs listed in the Compound Segment submitted as a compound code “01-Not a compound” will not be accepted. A new claim edit has been developed to ensure this requirement.
|eMedNY Edit Number/Message|
|“02326” Drug only covered in compound||“8H” Product/service only covered on compound claim|
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From The County To The State
- Prior to 2011 Medicaid transportation was administered by county Departments of Social Services.
- The 201011 State Budget gave the Commissioner of Health the authority to assume the administration of Medicaid transportation from the counties.
- The 2010 Medicaid Administration Reform and subsequent Medicaid Redesign Team initiatives intended to improve the program by:
- Relieving the counties with the burden administering Medicaid transportation
- Improving program quality
- Achieving greater department accountability
- Standardizing the application of Medicaid transportation policy
Medicaid Chronic Care Nursing Home Placement
- Placement of Albany County residents in Nursing Homes
- Pickup of Albany County residents already in Nursing Homes
- Long Term Home Health Care cases Married couples where one is looking for a waiver program:
- Nursing Home Transition Diversion or Traumatic Brain Injury or to enroll in a Managed Long Term Care Plan . This allows a spouse to receive care at home and still qualify for Medicaid.
Please call the above number for further information.
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Questions And Additional Information:
- Fee-for-service claim questions should be directed to the eMedNY Call Center at 343-9000.
- FFS coverage and policy questions should be directed to the Office of Health Insurance Programs Division of Program Development and Management by telephone at 473-2160 or by email at .
- FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at 486-3209 or by email at .
- Medicaid Managed Care general coverage questions should be directed to the OHIP Division of Health Plan Contracting and Oversight by email at or by telephone 473-1134.
- MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee´s MMC Plan.
Sickle Cell Disease Now A Single Qualifying Condition For The Medicaid Health Home Program
The New York State Department of Health is expanding eligibility requirements for enrollment in the NYS Medicaid Health Home program. This expansion, approved on March 24, 2022 by the Centers for Medicare and Medicaid Services in State Plan Amendment #21-0026, includes sickle cell disease as a single qualifying condition for Health Homes Serving Adults and Health Homes Serving Children . Please note:Medicaid State Plan Amendment can be accessed via the NYS DOH “Medicaid Health Homes – State Plan Amendments” web page.
Individuals enrolled in the NYS Medicaid Health Home program must also meet appropriateness criteria, which includes significant behavioral, medical, or social risk factors requiring intensive care management services, and have:
- two or more chronic conditions, or
- one single qualifying condition, such as:
- human immunodeficiency virus /acquired immunodeficiency syndrome , or
- serious mental illness , or
- serious emotional disturbances , or
- complex trauma , or
- new: SCD.
- managing the comorbidities associated with SCD,
- understanding pain and pain control/management issues,
- recognizing self-care and self-efficacy,
- acknowledging and addressing social determinants of health,
- connecting to community support services and appropriate educational information.
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Cost And Coverage Of Medicaid In New York
Estimates for the cost of Medicaid can vary depending on things like the individual patient and services needed. These copays will be small. People who will receive free healthcare from Medicaid include those who are under the age of 21, women who are pregnant, and patients who are in long-term care.
As far as coverage goes, Medicaid typically pays for most medical services, along with any medications and supplies that are needed. This includes coverage for things like:
- Family planning services and prenatal care
- Ambulance rides to the hospital in emergency situations
- Public transportation or car mileage to the patients medical appointments
- Medicines, supplies, medical equipment, and appliances
- Early screening, diagnosis, and treatment for beneficiaries who are under 21
- Other various services that might be needed