New York State Medicaid Update - August 2024 Volume 40 - Number 8

In this issue …

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.

Important Update to Doula Services for Pregnant and Postpartum People

Coverage of doula services by Medicaid Managed Care (MMC) Plans is delayed until January 1, 2025. Doula services provided to MMC enrollees between March 1, 2024, and December 31, 2024, will continue to be billed to Medicaid fee-for-service (FFS). Effective January 1, 2025, doula services will be covered by MMC Plans [inclusive of mainstream MMC Plans, Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), as well as Health and Recovery Plans (HARPs)].

New York State (NYS) Medicaid members, including NYS Medicaid members enrolled in MMC, are eligible for doula services during pregnancy and up to 12 months after the end of a pregnancy, regardless of the pregnancy outcome. If a NYS Medicaid member becomes pregnant within the 12 months following a prior pregnancy, their eligibility for doula services will start over with the new pregnancy and any unused perinatal doula services from the prior pregnancy will not carry over.

NYS Medicaid members, including NYS Medicaid members enrolled in MMC, will be eligible for coverage of doula services under the NYS Medicaid doula services benefit regardless of the amount of doula services they may have received through the NYS Medicaid Erie County Doula Service Pilot program. This article supersedes all previously published articles, guidance and policies pertaining to doula services. The NYS Medicaid Erie County Doula Service Pilot program ended as of February 29, 2024, and this statewide doula services benefit and the associated policy and billing guidance take the place of the coverage, policy, and billing guidance provided under the program.

Doula services are a preventative health service, and as such, must be recommended by a physician or other licensed practitioner of the healing arts acting within their scope of practice under State law to be eligible for NYS Medicaid reimbursement. Licensed providers of perinatal and maternity care services are to discuss the benefits of doula care with NYS Medicaid members, and as long as it is clinically appropriate, to provide all such MMC enrollees with a recommendation for doula services.

Please note: On June 10, 2024, the NYS Commissioner of Health (COH) issued a standing order, titled Non-Patient-Specific Standing Order for the Provision of Doula Services for Pregnant, Birthing and Postpartum Persons, which fulfills the federal requirements in §440.130(c) of title 42 of the Code of Federal Regulations, for a physician or other licensed practitioner of the healing arts acting within their scope of practice to provide a written order for preventive services. As such, on or after June 10, 2024, NYS Medicaid members who have a recommendation for doula services issued by a physician do not need an additional recommendation for doula services to be eligible for coverage by NYS Medicaid.

A doula is a public health worker, not otherwise recognized as a licensed or certified NYS Medicaid provider type, that provides direct support, education, and advocacy to the pregnant, postpartum and post-pregnant populations. The doula will directly enroll as a NYS Medicaid doula services provider and will bill NYS Medicaid directly for doula services. The NYS Medicaid-enrolled doula does not require supervision. Doula services will include up to eight perinatal visits by a doula during and after pregnancy and one labor and delivery support encounter. Additionally, doula services may include:

  • intermittent support that aligns with personal and cultural preferences during the prenatal, childbirth, postpartum and newborn periods, regardless of pregnancy outcomes;
  • education, guidance, health navigation, and connections to community-based resources related to childbirth and parenting;
  • development of a birth plan and continuous labor support;
  • patient-centered advocacy, and physical, emotional, and nonmedical support;
  • facilitation of communication between the NYS Medicaid member and medical providers; and
  • discussion of the importance of perinatal and pediatric health services provided by a licensed health provider during pregnancy and labor and delivery, and after pregnancy and the birth of the infant.

Billing NYS Medicaid FFS During MMC Carve-Out

Doula services are carved-out of the MMC Plan benefit packages from March 1, 2024 through December 31, 2024. NYS Medicaid members who are enrolled in NYS Medicaid FFS or MMC Plans are eligible for NYS Medicaid coverage of doula services during and after the MMC carve-out. During the MMC carve-out period (March 1, 2024 through December 31, 2024), all covered doula services are to be billed to NYS Medicaid FFS, even for NYS Medicaid members who are enrolled in an MMC Plan. Doula services will only be reimbursed when provided by doulas that have enrolled as NYS Medicaid providers. Effective January 1, 2025, covered doula services will be added to the MMC Plan benefit package and reimbursable by MMC Plans.

NYS Medicaid FFS Billing Information

Doula services are provided on an individual basis with the NYS Medicaid member. To qualify for NYS Medicaid reimbursement for perinatal doula services, the service:

To qualify for NYS Medicaid reimbursement for labor and delivery doula services, the service:

  • must involve a direct interaction with the NYS Medicaid member;
  • must be provided to the NYS Medicaid member in-person except in extenuating circumstances, such as illness, emergency, or precipitous birth, in which case the current telehealth policy will apply; and
  • must be in attendance by a licensed perinatal services provider in order for the doula to be reimbursed for the labor and delivery encounter.

Additionally, reimbursement is not available for service visits/appointments that are not kept, and multiple visits are not allowed in the same day, except for the following instances:

  • a perinatal doula visit occurs early in the day and a labor and delivery doula visit occurs later in the day, or
  • a labor and delivery doula encounter occurs early in the day and a perinatal doula visit occurs later in the day.

NYS Medicaid providers are not allowed to balance bill NYS Medicaid members, including NYS Medicaid members enrolled in MMC; payment received from NYS Medicaid is considered payment in full for services rendered.

Doula Services Healthcare Common Procedure Coding System (HCPCS) Procedure Codes

HCPCS Code Diagnosis Code(s) Code Description Service Description Per Pregnancy Allowance Reimbursement Rate
T1032 Z32.2
(prenatal/ pregnancy)

Z32.3
(postpartum)		 Services provided by a doula birth worker. Perinatal Service:
Prenatal or postpartum doula support (minimum of 30 minutes).		 Up to and including eight times. NYC:
$93.75 per visit

Rest of State:
$84.37 per visit
T1033 Z32.2 Services provided by a doula birth worker, per diem. Labor and Delivery:
In-person doula support during labor and birth (no time minimum, must be present for the birth).		 Up to and including one time. NYC:
$750

Rest of State:
$675.00

MMC Billing Instructions

During the MMC carve-out period (March 1, 2024 through December 31, 2024), NYS Medicaid-enrolled doulas who elect to contract with MMC Plans may negotiate or renegotiate MMC contracts in preparation for reimbursement of eligible doula services. For dates-of-service (DOS) on or after January 1, 2025, doulas who have a contract with an MMC Plan will be reimbursed by the MMC Plan for all eligible doula services.

After MMC carve-out period (January 1, 2025, and after), if an MMC enrollee is receiving services prior to January 1, 2025, MMC Plans are required to cover the doula services and continue the NYS Medicaid FFS equivalent until 12 months after the end of the pregnancy, regardless of pregnancy outcome. Additionally, requirements include the following:

  • The doula is required to begin billing the MMC Plan of the enrollee for DOS on or after January 1, 2025;
  • The MMC Plan is required to ensure continuity of care for these services for MMC enrollees, even if the doula is not contracted with the MMC Plan as of January 1, 2025. Please note: This only applies if the MMC enrollee was receiving services from the billing doula prior to January 1, 2025.
  • The MMC Plan will reimburse no less than the NYS Medicaid FFS equivalent until 12 months after the end of the pregnancy, regardless of pregnancy outcome.

If an MMC enrollee has not received services prior to January 1, 2025, doula services will be reimbursed by the MMC Plan only if:

  • the doula is enrolled as a NYS Medicaid FFS provider;
  • the doula has contracted with the individual MMC Plan in which the NYS Medicaid member is enrolled; and
  • the doula is billing the MMC Plan.

For NYS Medicaid members enrolled in MMC, providers must contact the MMC Plan of the enrollee for billing instructions that apply on and after January 1, 2025. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

Questions and Additional Information:

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Home Sleep Test

Effective October 1, 2024, the New York State (NYS) Medicaid fee-for-service (FFS) program will reimburse for an at Home Sleep Test (HST), if a NYS Medicaid member meets the coverage criteria. NYS Medicaid Managed Care (MMC) Plans must comply, at a minimum, with this coverage, effective December 1, 2024. HSTs, also known as Unattended Sleep Studies or Home Sleep Apnea Tests (HSAT), are intended to help diagnose sleep disordered breathing conditions in the home-setting when medically appropriate. A sleep technologist or qualified healthcare professional is not physically present with the patient during the recording session of an HST.

NYS Medicaid FFS Coverage Criteria for HST

NYS Medicaid FFS coverage for HST is limited to NYS Medicaid members who would experience difficulty traveling to a sleep lab for a lab-based sleep test (polysomnography) due to mobility issues [e.g., NYS Medicaid members who need assistance with ambulation or use a Durable Medical Equipment (DME) to ambulate, such as a wheelchair or a walker] as long as the HST is a medically appropriate alternative for the NYS Medicaid member.

For NYS members who meet the above coverage criteria, healthcare providers should use their clinical judgement to determine if a HST is a medically appropriate alternative to a lab-based sleep test (polysomnography). Additionally, HST raw data must be reviewed and interpreted by a Sleep Medicine specialist who is either board-certified or board-eligible in Sleep Medicine.

Age

Adults 18 years of age and over who meet the NYS Medicaid FFS coverage criteria for HST are eligible for HST. The American Academy of Sleep Medicine (AASM) does not recommend the use of HST for the diagnosis of Obstructive Sleep Apnea (OSA) in children because of insufficient evidence indicating its validity to identify OSA in children at this time.

NYS Medicaid HST Access

A Sleep Medicine specialist evaluates the NYS Medicaid member and orders a HST if medically appropriate and if needed. The Sleep Medicine specialist or Sleep Lab then provides the prescribed HST equipment and counsels the NYS Medicaid member on how to compete the HST.

Limitation
HST is not medically appropriate for everyone. HST can only be used to diagnose sleep disordered breathing conditions, such as OSA, and cannot be used to diagnose other sleep disorders. HST results may sometimes be inaccurate due to multiple factors relating to the inherent nature of home-based sleep testing and may sometimes underdiagnose the severity of OSA. It is imperative that health care providers use good clinical judgement when determining if a HST is a medically appropriate alternative to a lab-based sleep test (polysomnography).

Frequency
HST can only be billed once per year. If a repeat HST is needed before the one-year mark, persuasive medical evidence will be required. Repeat studies may be indicated for the following situations:

  1. If the first study was technically inadequate due to equipment failure.
  2. If the NYS Medicaid member did not know how to operate the HST equipment correctly or did not sleep for a sufficient amount of time to allow a clinical diagnosis.

For positive test results and prescribing of positive airway pressure equipment (PAP therapy), providers should refer to the eMedNY New York State Medicaid Provider Procedure Code Manual - Physician Medicine, Drugs and Drug Administration Procedure Code.

Patient Rights and Consent

The treating health care provider shall provide the member with information about HST and obtain consent from the patient. Written consent is not required, but the health care provider must document informed consent in the chart of the patient.

Documentation

The following must be documented in the medical records of the patient:

  1. Documentation of informed consent by the patient.
  2. Documentation supporting the medical necessity for sleep testing must be maintained in the clinical file of the ordering physician.
  3. Documentation of patient history, physical exam, and healthcare provider assessment that prompted the need for an HST must be in the file prior to HST.
  4. Documentation of the HST outcome/test results.

Billing

Orders for sleep testing are limited to Sleep Medicine specialists who are fellowship-trained and board-certified/board-eligible and may include family medicine physicians, internal medicine physicians, pediatricians, psychiatrists, neurologists, pulmonologists, and otolaryngologists. Physician specialists should refer to the table below when billing, as well as the following orders:

  • Do not report Current Procedure Code (CPT) code "95800", in conjunction with CPT codes "93041" through "93227", "93228", "93229", "93268" through "93272", "95801", "95803", and "95806".
  • Watchpat must be billed as CPT code "95800".
  • If a sleep study is performed for less than six hours, it should be billed with modifier "52".
  • Bundled under the one rate includes cost of equipment, the assessment, and interpreting results.
CPT Code Modifier Description NYS Medicaid Rate
95800 N/A Sleep Study, unattended, simultaneous recordings; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time. $117.08
95800 TC Physician provides the test only. $32.40
95800 26 Physician only interprets the results. $84.68

Questions and Additional Information:

Medicaid FFS billing and claims questions should be directed to the eMedNY Call Center at (800) 343-9000.

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Medicaid Managed Care for Undocumented Non-Citizens 65 Years of Age and Older Nursing Home Benefit

Effective January 1, 2024, undocumented non-citizens who are 65 years of age and older are eligible for comprehensive health insurance coverage through a mainstream Medicaid Managed Care (MMC) Plan. Consumers enrolled in their MMC Plan receive coverage code "37". Prior to enrollment, consumers will have coverage code "38". Medicaid Eligibility Verification System (MEVS) responses for these coverage codes are:

  • "37" - "Eligible primary care provider (PCP), 65 years of age and older, with pharmacy carve out"
  • "38" - "Eligible fee-for-service (FFS), 65 years of age and older, pharmacy, emergency only"

Consumers enrolled in an MMC Plan with coverage code "37" are eligible for covered plan services and pharmacy benefits through NYRx, the Medicaid Pharmacy program. Long-term nursing facility services are available in mainstream MMC Plans. As such, undocumented non-citizens 65 years of age and older, who are otherwise eligible [e.g., income eligible, New York State (NYS) resident] for NYS Medicaid coverage of long-term nursing facility services will access this benefit through their mainstream MMC Plan. Undocumented non-citizens 65 years of age and older are not eligible to enroll in other types of MMC Plans, including Managed Long-Term Care (MLTC), Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs), Fully Integrated Dual Eligible (FIDA) or Program of All-Inclusive Care of the Elderly (PACE).

Facilities assisting non-New York City (NYC) residents with applying for long-term nursing home benefits will continue to send all required application documentation to the appropriate Local Department of Social Services (LDSS). The LDSS will forward application documentation to the NYS Department of Health (DOH) for an eligibility determination. Facilities assisting NYC residents with applying for long-term nursing home benefits need to fax application documentation to the NYS DOH at (518) 408-9792. Providers are encouraged to separate faxes by consumer.

Undocumented non-citizens 65 years of age and older only receive the expanded health insurance coverage through MMC Plans. Coverage for long-term nursing services will only be available once the consumer is enrolled in a plan and the plan has approved the placement.

Questions

Questions regarding this coverage expansion or eligibility should be directed to MCfor65PlusUndoc@health.ny.gov.

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Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans and Human Immunodeficiency Virus-Special Needs Plans (HIV-SNPs)], will reimburse providers for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program when provided to NYS Medicaid members under 21 years of age. Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP).

Providers may bill for childhood vaccine counseling provided to NYS Medicaid members under 21 years of age. Please note: Through December 31, 2024, childhood vaccine counseling may be provided by a pharmacy in accordance with the Public Ready and Emergency Preparedness (PREP) Act. Additionally, childhood vaccine counseling may be provided:

  • as a stand-alone service when all the criteria specified in this guidance are met and documented;
  • in addition to an Evaluation and Management (E&M) 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; and
  • for up to six counseling visits per NYS Medicaid member, per year, for NYS members zero years of age through 18 years of age, when they have not received the ACIP-recommended doses and does not have an appointment to receive the recommended dose.

The childhood vaccine counseling session must be documented in the medical or pharmacy record and must include the following:

  • confirmation from the parent, guardian, caregiver, or patient (if appropriate) that the patient is not currently "up to date" with childhood vaccination doses [providers can refer to the vaccine schedules provided on the Centers for Disease Control and Prevention (CDC) "Vaccine Schedules For You and Your Family" web page];
  • confirmation of vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible;
  • confirmation that the patient does not have an appointment scheduled to receive the vaccine dose for which they are being counseled;
  • reason(s) expressed by the parent or caregiver for vaccine hesitancy;
  • recommendation of the vaccine(s);
  • counseling the parent, guardian, caregiver, or patient (if appropriate), on the safety and effectiveness of the vaccine(s);
  • answer any questions that the parent, guardian, caregiver, or patient (if appropriate) have regarding the recommended vaccine(s); and
  • counseling the parent, guardian, caregiver, or patient (if appropriate) for a minimum of eight minutes;
    and
  • arrangement for vaccination(s) or providing information to the parent, guardian, caregiver, or patient (if appropriate) on how the patient can get vaccinated.

Clinics, Hospital Outpatient Departments, Physicians, Nurse Practitioners and Midwives

A provider submitting professional claims should bill Current Procedure Terminology (CPT) code "99401" for preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required.

CPT Code Code Description Fee
99401 Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure). $12.63

Questions and Additional Information:

  • FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
  • MMC general coverage questions should be directed to the OHIP Division of Health Plan Contracting and Oversight (DHPCO) by email at covques@health.ny.gov or by telephone at (518) 473-1134.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the MMC Plan of the enrollee.
  • MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

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New York State Medicaid Pharmacy Policy for Coronavirus Disease 2019 Testing

Effective October 1, 2024, with the expiration of the Public Health Emergency (PHE) and provisions in the American Rescue Plan Act (ARPA), NYRx, the New York State (NYS) Medicaid Pharmacy program, will no longer provide coverage for Coronavirus Disease 2019 (COVID-19) testing when administered in a pharmacy or dispensed as a kit for at-home use. Coverage of COVID-19 testing will continue to be provided to eligible NYRx members when administered by a NYS Medicaid-enrolled practitioner in-office or performed by a clinical laboratory.

Additional information can be found on the in the eMedNY New York State Medicaid Program - Physician Policy Guidelines manual.

Medicaid Managed Care

Coverage of COVID-19 testing will continue to be provided for Medicaid Managed Care (MMC) enrollees via their MMC Plan. Individual MMC Plans should be contacted for their specific reimbursement/billing guidelines, and/or documentation requirements.

Additional Information:

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New York State Medicaid Coverage for Coronavirus Disease 2019 Vaccines for Eligible Vaccine For Children Program Members at the Pharmacy

Effective January 1, 2025, with the expiration of the Public Health Emergency (PHE) and provisions in the Public Readiness and Emergency Preparedness (PREP) Act, New York State (NYS) Medicaid will revert to pre-pandemic processing of vaccines for NYS Medicaid members younger than 19 years of age. Pharmacy providers administering Coronavirus Disease 2019 (COVID-19) vaccines to Vaccine For Children (VFC) program-eligible NYS Medicaid members must be enrolled in VFC as of January 1, 2025. Alternatively, pharmacies that are not enrolled in the VFC program may choose to provide COVID-19 vaccines for NYS Medicaid members younger than 19 years of age, at no charge, to the NYS Medicaid member or to NYS Medicaid, and will be reimbursed for vaccine administration only.

Additional Information and Questions:

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Introduction to Upcoming Pharmacy and Practitioner Administered Drug Changes Due to Enacted Budget

In accordance with the enacted 2024-25 budget and Chapter 57 of the Laws of 2024, the New York State (NYS) Medicaid program will make the following program updates:

  • Effective October 1, 2024, the pharmacy reimbursement benchmark for wholesale acquisition cost will be modified in the lower of methodology for brand prescription drugs to:
    • Wholesale acquisition cost (WAC) instead of WAC minus 3.3 percent.
  • Practitioner Administered Drug (PAD) reimbursement methodology and process for drugs provided and claimed separately by a medical practitioner will change to the lower of:
    • National Average Drug Acquisition Cost (NADAC); or
    • WAC (in the event of no NADAC pricing available); or
    • Federal Upper Limit (FUL); or
    • State Maximum Acquisition Cost (SMAC); or
    • the actual cost of the drug to the practitioner.

Please note: Information including implementation dates, billing guidance, appeal and any retroactive claim reimbursement will be shared in subsequent Medicaid Update articles regarding the above changes.

Questions

Questions regarding program changes should be directed to NYRx, the Medicaid Pharmacy program, by email at NYRx@health.ny.gov or by telephone at (518) 486-3209.

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The Medicaid Update is a monthly publication of the New York State Department of Health.

Kathy Hochul
Governor
State of New York

James McDonald, M.D., M.P.H.
Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs