This article provides an overview of significant updates relevant to long term care coding and billing, derived from the New York State Medicaid Update – April 2018 Volume 34 – Number 4. While this document is not strictly a “coding guidelines” document, it outlines crucial policy changes and initiatives enacted in 2018 that directly impact coding, billing, and reimbursement for long term care services within the New York Medicaid program. Providers should carefully review these updates to ensure compliance and accurate claims submission.
Medicaid Transportation Ambulance Rate Increase
Effective April 1, 2018, New York State Medicaid implemented an increase in ambulance fees for both emergency and non-emergency transports. This change, part of the 2018-2019 Enacted Budget, allocated $12.56 million to enhance Medicaid ambulance service reimbursement. The fee adjustments apply to Advanced Life Support (ALS) and Basic Life Support (BLS) levels of service.
Ambulance services are vital components of healthcare, and this rate increase acknowledges their critical role in patient care.
Providers should consult the updated fee schedules available on the eMedNY website (https://www.emedny.org/ProviderManuals/Transportation/index.aspx) to ensure accurate billing for dates of service on or after April 1, 2018. For any queries regarding transportation billing, the Bureau of Medicaid Transportation can be contacted at (518) 473-2160 or via email at [email protected].
Center of Operational Excellence: Focus on Cost Avoidance and Fraud Prevention
The Office of Health Insurance Programs introduced a Center of Operational Excellence in 2018, aiming to improve cost efficiency and strengthen measures against fraud, waste, and abuse within Medicaid. A primary focus of this center is to enhance claims editing processes. This involves system improvements and increased staffing to monitor claim edits, ensuring adherence to national standards. Additionally, the center is scrutinizing delays in claim filings to identify and rectify inefficiencies.
Data analytics play a crucial role in modern healthcare administration, enabling the detection and prevention of fraud and waste.
Another key area of attention for the Center is dental fraud, waste, and abuse detection. By leveraging advanced data analytics software, the initiative aims to identify anomalies and data discrepancies that may indicate improper payments or fraudulent activities. These tools enhance the state’s capacity to detect and prevent financial irregularities within the Medicaid dental program. For further details on this initiative, inquiries can be directed to [email protected].
Health Home Program Performance and Quality Initiatives
The 2018-2019 Enacted Budget included several performance-based initiatives for the Health Home Program, designed to incentivize quality and efficiency in care management. These initiatives, effective April 1, 2018, focus on improving health outcomes for high-risk Medicaid members through enhanced care coordination.
Health Home Quality Performance Management Program
A significant component is the Health Home Quality Performance Management Program. This program integrates performance goals set by the Centers for Medicare and Medicaid Services (CMS) and metrics developed under the State’s Health Home Quality Improvement Program into a Quality Performance Pool. This pool creates financial incentives for Health Homes and care management agencies that achieve established performance benchmarks.
Performance metrics are essential for evaluating and improving healthcare delivery, ensuring quality and accountability.
Managed Care Plans are provided access to Health Home performance data, fostering transparency and accountability. The Incentive Pool operates by penalizing underperforming entities and rewarding high performers, redistributing funds based on pre-defined quality targets. These targets include standardized measures already in use, as well as process measures like adherence to face-to-face engagement requirements for high-risk adults and maintaining recommended caseload sizes. Flexibility in process requirements may be granted for Health Homes engaging in value-based payment arrangements that include care management.
Additional quality performance activities include evaluating cost reporting to capture more detailed cost and volume data for care management, ensuring compliance with Regional Health Information Organizations (RHIOs) for case management and service connectivity, and publishing public reports on Health Home quality data, including comparative scorecards.
Health Home Healthy Rewards Program
The Health Home Healthy Rewards program, administered by Managed Care Plans, is designed to promote wellness among adult Health Home enrollees (21+). The program encourages proactive engagement in preventative care and sustained participation in Health Home care management. Rewards are provided to members for participating in wellness activities such as annual physicals, maintaining a healthy BMI, smoking cessation, and continuous Health Home enrollment. This program aims to reduce preventable emergency visits and inpatient stays, thereby generating Medicaid savings.
Incentives for High-Risk Member Enrollment in Health Homes
To ensure comprehensive care management for high-risk, high-need, high-cost Medicaid members, the budget introduced penalties for Managed Care Plans failing to enroll target percentages of eligible Health and Recovery Plan (HARP) members and other high-risk adults and children in Health Homes. These penalties, up to 50 percent of which may be passed to Health Homes, incentivize collaboration between Plans and Health Homes to enroll high-risk individuals. Penalty structures are tiered, increasing with greater deviations from enrollment targets. This incentive applies across HARP, HIV/SNP, and mainstream plans.
Restructuring Outreach Resources for Health Home Enrollment
Effective October 1, 2018, outreach resources for Health Homes were restructured to directly involve Managed Care Plans in identifying, locating, and enrolling high-risk members. Plans were required to submit detailed Outreach Plans to the Department for approval by August 1, 2018, outlining strategies to optimize outreach resources and payments. These plans needed to include projected enrollment numbers based on the Plan’s analysis of high-risk criteria.
Effective outreach is crucial for connecting vulnerable populations with necessary healthcare services.
Plans were encouraged to build upon successful Health Home and Delivery System Reform Incentive Payment (DSRIP) activities, potentially including Health Home outreach staff in shelters, hospitals, and Local Departments of Social Services (LDSS). Plans are responsible for documenting and tracking the use of outreach resources and leveraging their data to assist Health Homes in identifying and locating eligible members. This restructured approach aims to enhance efficiency, allowing Health Homes to focus more on care management and service linkage, including Home and Community Based Services (HCBS). The State also committed to developing model outreach approaches that would not require prior approval.
New Background Check Requirements for Health Homes and Children’s HCBS Providers
Statutory amendments in 2018 mandated background checks and Statewide Central Register checks for new Health Home care managers and HCBS providers serving Medicaid children and members with intellectual and developmental disabilities (I/DD). These providers are also designated as mandated reporters. Webinars were scheduled in April and May 2018 to inform providers about these new requirements. Further information is available on the Health Home Serving Children web page. For inquiries, contact the Office of Health Insurance Programs at 518-476-5569 or via the Health Home email web page.
Managed Long-Term Care (MLTC) Plan and Licensed Home Care Service Agency (LHCSA) Updates
The 2018 Enacted Budget introduced significant changes affecting Managed Long-Term Care (MLTC) partial capitation plans and Licensed Home Care Service Agencies (LHCSAs), aiming to refine network management and oversight.
Limitation on LHCSA Contracts for MLTC Partial Capitation Plans
Effective October 1, 2018, a new statutory provision (§4403-f(7)(j) of the Public Health Law) set maximum limits on the number of LHCSAs that MLTC partial capitation plans can contract with. This phased approach, implemented over two years, is based on plan enrollment and geographic location, distinguishing between Downstate (NYC, Nassau, Suffolk, Westchester) and Rest of State (ROS) regions.
Strategic contract management is essential for maintaining quality and efficiency in healthcare networks.
By October 1, 2018, maximum ratios were set at 1 LHCSA per 75 enrollees Downstate and 1 LHCSA per 45 enrollees ROS. By October 1, 2019, these ratios adjusted to 1:100 Downstate and 1:60 ROS. Plans operating in both regions must meet the requirements for each separately. These limitations do not restrict the number of enrollees an LHCSA can serve, and apply to both direct and indirect contracts, including those through intermediary entities like Independent Practice Associations (IPAs). Network adequacy standards remain a minimum requirement.
LHCSA Moratorium
A two-year moratorium on licensing new LHCSAs was enacted, effective April 1, 2018. Limited exceptions may be considered by the Public Health and Health Planning Council (PHHPC) for applications meeting specific criteria, such as provision of new Assisted Living Program (ALP) services, consolidation of licensees, geographic access, or addressing inadequate care as determined by the Commissioner. The moratorium applied to all pending applications not approved by PHHPC as of April 1, 2018. During this period, the Department of Health was tasked with developing a licensure process incorporating public need and financial feasibility assessments.
LHCSA Registration Requirement
Public Health Law §3605-b, introduced in the 2018 budget, mandates annual registration for LHCSAs with the Department. Starting January 1, 2019, unregistered LHCSAs are prohibited from operating, providing services, or receiving reimbursement. Failure to register by the deadline incurs a penalty of $500 per month. Failure to register in the prior year by the current year’s deadline prevents registration until unpaid fees are settled. License revocation may occur for failure to register for two annual periods, consecutive or not, or for a pattern of late registrations. The Department publishes a list of LHCSAs with their registration status on its website. Inquiries can be directed to [email protected].
Managed Long-Term Care Plan Closure Oversight
Effective April 1, 2018, the Department of Health implemented enhanced oversight for MLTC plan closures, mergers, acquisitions, or similar transactions involving involuntary enrollee transitions. Receiving plans are required to submit a report approximately one year post-transaction, in addition to complying with MLTC Policy 17.02, which provides 120 days of continuity of care for transitioned enrollees.
Rigorous oversight of plan transitions is critical to ensure uninterrupted care for vulnerable populations.
For transactions involving fewer than 1,000 transferred enrollees, the report must list each enrollee (by CIN) remaining with the receiving plan after one year, their personal care hours at transfer and one year later, the percentage change in hours, and explanations for any hour reductions. For larger transactions (1,000+ enrollees), the receiving plan submits a list of enrollees, from which the Department selects a random sample for reporting. Reports must be certified by a plan officer. The Department may further select a random sample for which supporting documentation of personal care services is required. De-identified reports will be made public. Questions can be directed to [email protected].
Patient Centered Medical Home (PCMH) Statewide Incentive Payment Program Revisions
The 2018-2019 Enacted State Budget revised the reimbursement structure for providers in Patient Centered Medical Home (PCMH) recognized practices, effective May 1, 2018. This policy, applicable to both Medicaid Managed Care (MMC) and Fee-For-Service (FFS), replaced the January 2018 policy and established a $200 million spending cap for the PCMH incentive program for State Fiscal Years 2018-2019 and 2019-2020.
Incentive programs are designed to encourage adoption of best practices and improve healthcare quality.
For May and June 2018, practices recognized under NCQA 2014 Level 3, NCQA 2017, or NYS PCMH standards received a MMC incentive of $5.75 PMPM. FFS add-on amounts remained at $29.00 (professional) and $25.25 (institutional). PCMH incentive payments for NCQA 2014 Level 2 recognition were eliminated from May 1, 2018. Beginning July 1, 2018, the MMC incentive increased to $6.00 PMPM, while FFS add-on amounts remained unchanged. These amounts were set to remain through the end of SFY 2018-2019. Future changes may link PCMH incentives to Value Based Payments (VBP) and quality metrics. Refer to the April 2017 and June 2016 Medicaid Update issues for further details on FFS policy, billing guidance, and included plan types.
New York State Medicaid Coverage for Professional Glucose Monitoring for Type 1 Diabetics
New York State Medicaid (FFS and MMC) began covering short-term (3-7 days) professional glucose monitoring for uncontrolled Type 1 diabetics. This coverage became effective April 1, 2018, for FFS and July 1, 2018, for MMC.
Continuous glucose monitoring is a valuable tool for managing diabetes and improving patient outcomes.
MMC providers should consult individual health plans for implementation details. FFS providers, within their scope of practice, can bill for equipment, sensor placement, calibration, training, sensor removal, and reading printout, reimbursable twice per year. Analysis, interpretation, and reporting are billable once per monitoring period. Billable CPT codes include 95250 (equipment, placement, etc.) and 95251 (analysis, interpretation, report). Policy questions can be directed to (518) 473–2160; billing/claims questions to (800) 343–9000.
Reminder on Medicaid Coverage for Immigrants in Nursing Homes
Nursing Home and Long-Term Care providers were reminded that Qualified Non-Citizens (LPRs, refugees, asylees, etc.) and individuals Permanently Residing Under Color of Law (PRUCOL), including “Aliessa” individuals in the Essential Plan (EP), are entitled to Medicaid coverage for nursing home care if otherwise eligible. Immigration status (PRUCOL or Qualified Non-Citizen) should not factor into determining need or admittance. Eligibility is based on individual need and Medicaid eligibility, not immigration status.
Ensuring equitable access to long-term care for all eligible individuals is a fundamental principle of healthcare.
NY State of Health and LDSS determine immigration eligibility for Medicaid/Essential Plan. Individuals deemed eligible have met immigration requirements for Medicaid coverage, including long-term nursing home care. Individuals with NY State of Health coverage (H78 code in ePACES) needing permanent nursing home placement must have their case transferred to LDSS for nursing home Medicaid eligibility determination. Providers can notify LDSS or NY State of Health of the need for case transition. LDSS notification can be done by submitting the Medicaid application (DOH-4220), Supplement A (DOH-4495A), and LDSS-3559 form. NY State of Health can be notified via email at [email protected]. Providers are encouraged to assist individuals with application completion. Refer to the April 2016 Medicaid Update for additional information.
New Date for Taxi and Livery Claims Requirements
Taxi (Category 0603) and Livery (Category 0605) providers were reminded of documentation requirements for claims, initially published in December 2015 Medicaid Update. Claims lacking required documentation would face denial. Agreements with the Office of the Medicaid Inspector General and the Attorney General’s Medicaid Fraud Control Unit mandated inclusion of both driver license and vehicle license plate numbers on claims to enhance service quality and program integrity. Effective May 24, 2018, claims missing these fields would be denied with edit 00267 (“VEHICLE LICENSE PLATE / DRIVER’S LICENSE NUMBER REQUIRED.”). Questions can be directed to the Medicaid Transportation Unit at (518) 473-2160 or [email protected], or [email protected].
Medicaid Pharmacy Prior Authorization (PA) Programs Update
Changes to Medicaid pharmacy prior authorization (PA) programs, recommended by the NYS Medicaid Drug Utilization Review (DUR) Board on February 15, 2018, were implemented effective April 19, 2018.
Prior authorization programs are designed to ensure appropriate medication use and manage healthcare costs.
Updates included:
- Second Generation Antipsychotics: Prescriber involvement required for using three or more different oral second-generation antipsychotics for over 180 days. Informational letters for prescribers with a history of prescribing three or more for over 90 days.
- Zolpidem IR Duration Limit: 30-day supply limit with maximum five refills (180 days).
- Codeine- and Tramadol-Containing Products: Prescriber involvement for all uses in patients under 12 years. Educational letters regarding prescribing updates.
- Initiation of Methadone Therapy: Diagnosis confirmation for chronic non-cancer pain required. Prescriber involvement if no covered diagnosis history. Step-therapy: trial with long-acting opioid prior to methadone for chronic non-cancer pain.
Detailed DUR Board information is available at http://www.health.ny.gov/health_care/medicaid/program/dur/index.htm. The Medicaid FFS Pharmacy PA Programs list is at https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf. For PA requests, contact the clinical call center at 1-877-309-9493 or use the PAXpress® web application on eMedNY.org. Additional information is at http://www.nyhealth.gov, http://newyork.fhsc.com, or http://www.eMedNY.org.
Update on Pharmacists Administering Influenza Vaccines for Medicaid Enrollees Under 19
Effective April 1, 2018, NYS certified pharmacists were authorized to administer influenza vaccines to children aged 2-18, per NYS Education Law section 6803. Influenza vaccines are provided free by the CDC through the Vaccine for Children (VFC) Program to VFC-enrolled pharmacies for Medicaid and uninsured children under 19. Pharmacies were encouraged to enroll in VFC.
Pharmacist-administered vaccinations enhance access to preventative care, particularly for vulnerable populations.
The suspension of the requirement to exclusively use VFC vaccines for enrollees under 19, due to Executive Order 176, ended with the Executive Order’s expiration on April 21, 2018. NYS Medicaid should not be billed for influenza vaccine costs for members under 19, as these are free through VFC. Billing Medicaid for VFC-available vaccines may result in payment recovery. Services must comply with NYS Department of Education laws. Immunizations for those under 19 must be reported to NYSIIS or the NYCwide Immunization Registry.
For NYS Medicaid FFS billing, use NCPDP D.0 with qualifier “09” (HCPCS) and procedure code 90460 for vaccine administration (reimbursement $17.85). No reimbursement for the vaccine itself. For Medicaid Managed Care billing, consult individual plans.
New HCPCS Code for Axicabtagene Ciloleucel (YESCARTA™)
Effective April 1, 2018, hospital claims for Axicabtagene Ciloleucel (YESCARTA™) should use HCPCS code Q2041. For claims from December 1, 2017, to March 31, 2018, use J3590 (unlisted biologic). YESCARTA™ is covered by NYS Medicaid for members 18+ with B-cell lymphoma, meeting specific criteria outlined in the January 2018 Medicaid Update.
NY Medicaid EHR Incentive Program Update
The NY Medicaid Electronic Health Records (EHR) Incentive Program has distributed over $903 million in incentives to NYS Medicaid providers since December 2011, promoting EHR adoption to improve care quality and reduce costs.
EHR incentive programs accelerate the adoption of technology that enhances healthcare delivery and patient care.
Eligible Professionals (EPs) who attested in the past remain eligible, even with skipped years or only prior Adopt, Implement, or Upgrade attestations. EPs attesting for the second time in 2017 can still receive all six years of incentives through 2021. Participation in Medicare MIPS does not preclude NY Medicaid EHR Incentive Program participation. Eligibility can be checked at https://health.data.ny.gov/Health/Medicaid-Electronic-Health-Records-Incentive-Progr/6ky4-2v6j/data or by calling 877–646–5410, Option 2, or emailing [email protected]. Preparation for 2017 Meaningful Use attestation is encouraged, with MEIPASS system availability announcements to come.
Tips to Prevent Rejection of Certification Forms
Providers are reminded to annually recertify their Electronic Transmitter Identification Number (ETIN) to avoid claim rejections. eMedNY sends two renewal notices before annual decertification. For new ETIN applications, a Certification Statement must accompany the Provider ETIN Application, both at http://www.emedny.org.
Accurate and timely administrative processes are essential for smooth healthcare operations and reimbursement.
To prevent form rejections:
- Use legible writing, no red ink.
- Ensure provider name and number match records. For individuals, use individual name; for groups, use group practice name.
- Include NPI (10 digits) or NY Medicaid MMIS Provider ID (8 digits) if NPI exempt.
- Use original ink signatures for provider and notary.
- Notary must include name of signer, official stamp (or notary number, expiration, signature).
Questions? Contact the eMedNY Call Center at (800) 343–9000.
This summary highlights key updates from the April 2018 New York State Medicaid Update, focusing on areas relevant to long term care coding and billing guidelines. Providers are encouraged to review the full original document and linked resources for complete details and to ensure ongoing compliance.
